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LIPPINCOTT'S 
NURSING  MANUALS 


CARE  AND  FEEDING  OF  INFANTS 
AND  CHILDREN 

A  TEXT-BOOK  FOR  TRAINED  NURSES 


WALTER  REEVE  RAMSEY,  M.D. 

Associate  Professor  of  Diseases  of  Children,  University  of  Minnesota, 

Associate  Visiting  Physician  to  the  University  Hospital,  Visiting 

Physician  to  St.  Paul  City  and  County  Hospital,  Medical 

Director  St.  Paul  Baby  Welfare  Association,  Etc. 


LIPPINCOTT'S 

NURSING    MANUALS 

FULL  CATALOGUE  FREE  ON  REQUEST 


Seventh  Revised  Editiim 

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CARE  AND  FEEDING 
OF  INFANTS  AND  CHILDREN 

A  TEXT-BOOK  FOR  TRAINED  NURSES 

By  WALTER   REEVE  RAMSEY,  of    University    of    Minnesota. 
280  pages;    123  illustrations.    $2.00  net. 

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Digitized  by  the  Internet  Archive 

in  2007  with  funding  from 

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To  nurse  a  sick  baby  back  to  health  frequently  takes  weeks  or  months  of  gentle,  patient, 
intelligent  handling.     Page  4. 


^. 


LIPPINCQTT'S  NURSING  MANUALS 

CARE  AND  FEEDING  OF 
INFANTS  AND  CHILDREN 

A  TEXT-BOOK  FOR  TRAINED  NURSES 

BY 
WALTER  REEVE  RAMSEY,  M.D. 

ASSOCIATE  PROFESSOR  OF  DISEASES  OF  CHILDREN,  UNIVERSITY  OF  MINNESOTA 

ASSOCIATE  VISITING  PHYSICIAN  TO  THE  UNIVERSITY  HOSPITAL,  VISITING 

PHYSICIAN   TO   ST.    PAUL  CITY   AND  COUNTY   HOSPITAL,    MEDICAL 

DIRECTOR     ST.    PAUL    BABY    WELFARE    ASSOCIATION,    ETC. 

INCLUDING  SUGGESTIONS  ON  NURSING 

BY 

MARGARET  B.  LETTICE 

SUPERVISING    NURSE    OF  THE    BABY   WELFARE  ASSOCIATION,  ST.   PAUL,    MINNESOTA 

AND 

NANN  GOSSMAN 

NURSE    IN    CHARGE    OF    CHILDREN'S    DEPARTMENT,   UNIVERSITY    HOSPITAL,  MINNE- 
APOLIS,  MINNESOTA 

123  ILLUSTRATIONS  ■ 


PHILADELPHIA  AND  LONDON 

J.  B.  LIPPINCOTT  COMPANY 
37^31 

MAY  18 


COPYRIGHT,   I916,  BY  J.   B.  LIPPINCOTT  COMPANY 


Electrotyped  and  printed  by  J.  B.  Lippiticolt  Company 
The  Washington  Square  Press,  Philadelphia,  U.  S.  A. 


-RT 
1^14 


PREFACE 

In  writing  a  text-book  for  nurses,  on  the  care  and  feeding  of 
infants  and  children,  I  have  tried  to  make  it  practical  and  at  the 
same  time  sufficiently  comprehensive  to  meet  the  increasing  de- 
mand for  a  broader  education  along  the  line  of  preventive 
medicine. 

The  anatomy  and  physiology  have  been  considered  only  in 
so  far  as  they  relate  directly  to  the  subject  of  child  welfare. 

The  chapters  on  feeding  are  the  result  not  only  of  a  large 
personal  experience  but  also  of  a  study  of  the  work  of  the  lead- 
ing pediatrists,  both  in  this  country  and  in  Europe. 

Although  the  discussion  of  the  pathological  conditions  com- 
mon to  infants  and  children  has  of  necessity  to  be  brief,  in  a 
work  of  this  kind,  I  have  endeavored  to  give  the  nurse  the 
sort  of  information  most  useful  to  her,  and  of  the  greatest  benefit 
to  the  public. 

I  am  greatly  indebted  to  Dr.  Josephine  Heminway  Kenyon,  of 
the  Teacher's  College  of  Columbia  University,  and  to  Miss  Ida 
M.  Cannon,  Chief  of  the  Department  of  Social  Service,  Massa- 
chusetts General  Hospital,  Boston,  for  many  valuable  sugges- 
tions made  by  them  in  reviewing  the  manuscript. 

I  wish  also  to  express  my  appreciation  to  Dr.  Wilson  G. 
Smillie,  of  the  Department  of  Hygiene,  Harvard  Medical 
School,  for  several  important  points  in  the  chapter  on  milk,  and 
to  Dr.  Bronson  Crothers,  who  helped  me  to  revise  the  manuscript. 

Walter  R.  Ramsey. 
St.  Paul,  May  i,  1916. 


CONTENTS 


CBAPTER  PACK 

I,  The  Development  of  Child- welfare  Work i 

II.  Anatomy  and  Physiology 8 

III.  Care  of  the  New-born  Infant 30 

IV.  The  Nursery  and  Its  Equipment 46 

V.  Time  to  be  Spent  Out  of  Doors 52 

VI.  Sleep 55 

VII.  Temperature 58 

VIII.  The  Growth  and  Development  of  the  Child 60 

IX.  Clothing  for  Infants 74 

X.  Exercises  for  Infants  and  Children 80 

XL  Breast  Feeding 85 

XII.  Artificial  Feeding 102 

XIII.  Puberty. 141 

XIV.  Delicate  Children 143 

XV.  Diseases  of  Nutrition 146 

XVI.  Jaundice  in  Babies  (Icterus) 158 

XVII.  The  Urine 159 

XVIII.  Ophthalmia  Neonatorum  (Gonorrheal  Ophthalmia).  ...   166 

XIX.  Defective  Vision,  Its  Causes  and  Significance 170- 

XX.  Tetanus 172 

XXI.  Cretinism  and  Myxcedema  in  Children 174 

XXII.  Congenital  Deformities:  Club-foot,  Congenital  Dis- 
location of  the  Hip;  Malformations  of  the  Lips, 
Tongue,  and  Palate 177 

XXIII.  Enlargement  of  the  Breasts  in  Infants 182 

XXIV.  Affections  of  the  Digestive  Tract 183 

XXV.  Diseases  of  Respiratory  Tract 197 

XXVI.  Diseases  of  the  Brain  and  Central  Nervous  System..  216 

XXVII.  Rheumatism  and  St.  Vitus's  Dance 231 

XXVIII.  Affections  of  the  Heart 235 

XXIX.  Affections  of  the  Skin 237 

XXX.  The  Infectious  Diseases 245 

XXXI.  Habits 276 


ILLUSTRATIONS 

FIGURE  .  PAGE 

Nursing  a  Sick  Baby  Back  to  Health Frontispiece 

1.  Sutures  and  Fontanelles 9 

2.  Cephalhasmatoma lo 

3.  Skull  of  Adult II 

4.  Skull  of  Infant 11 

5.  Chest  of  Adult 11 

6.  Chest  of  Infant 11 

7.  Spinal  Column  Showing  Natural  Curves 12 

8.  Diagram  of  Infant's  Circulation  Before  Birth 14 

9.  Diagram  of  Infant's  Circulation  After  Birth 15 

10.  First  Position  in  Performing  Artificial  Respiration 32 

11.  Second  Position  in  Performing  Artificial  Respiration 32 

12.  In  a  Properly  Prepared  Basket 33 

13.  Umbilical  Hernia 36 

14.  Application  of  Adhesive  Strap  for  Cure  of  Umbilical  Hernia 36 

15.  Yam  Truss  for  the  Treatment  of  Inguinal  Hernia 37 

16.  Shower  Bath 41 

17.  Folding  Bath-tub 42 

18.  Folding  Table 43 

19.  Shower  Bath  for  Infants.    The  Water  is  First  Mixed  in  the  Tank  to 

the  Proper  Temperature 44 

20.  The  Homsby  Bed 50 

21.  Screened  Bed,  Which  Can  be  Readily  Moved  About 53 

22.  Screened  Bed  Extending  from  the  Window 53 

23.  Taking  the  Temperature  by  the  Rectum 59 

24.  25.  Scales  for  Weighing  Babies  and  Older  Children 67 

26.  The  Weight  Curve  of  the  First  Year 68 

27.  Temporary  or  Milk  Teeth 70 

28.  Permanent  Teeth 70 

29.  Front  View  of  the  Upper  and  Lower  Models  of  a  Child,  13  years  of 

age. 71 

30.  Front  View  of  the  Upper  and  Lower  Models  of  Same  Child,  14  Years 

of  Age,  After  Orthodontic  Treatment 71 

31.  Hutchinson  Teeth 72 

32.  Diaper  Pinned  in  the  Proper  Manner 75 

33.  Waist  with  Broad  Shoulder  Straps  Fitting  Well  up  Against  the  Neck  76 

vii 


VlU  ILLUSTRATIONS 

34.  Waist  with  Narrow  vStraps  which  Fall  Out  on  the  Points  of  the 

Shoulders 76 

35.  Blanket  Wrap  for  Cold  Weather 77 

36.  Improper  Shape  of  Sole  of  Child's  Shoe,  and  Proper  Shape 78 

37.  Showing  Position  of  the  Foot  in  a  High-heeled  Shoe 79 

38.  At  Six  Months  the  Baby  not  Only  Lifts  Its  Head,  but  It  Begins 

Raising  Its  Body  on  Its  Arms 80 

39.  Nursery  Pen 81 

40.  Improper  Curvature  of  the  Spine 81 

41.  A  Young  Child  in  a  Bad  Go-cart 82 

42.  A  Few  Exercises  which  May  be  Practised  Daily  to  Advantage 83 

43.  Colostrum  Corpuscles 87 

44.  English  Breast-pump 89 

45.  Proper  Position  for  Nursing  the  Baby  While  Lying  Down 92 

46.  If  There  are  Fissures,  a  Nipple  Shield  Should  be  Worn  at  Each 

Nursing 93 

47.  Feeder  for  Premature  Infant 97 

48.  Teterelle  Breast-pump,  for  Premature  Infants 98 

49.  Improvised  Incubator 99 

50.  Dirty  Barnyards,  Wasteful  of  Manure  and  Increasing  Expense  of 

Keeping  Cows  Clean 103 

51.  A  Dirty  Stable • 104 

52.  Open  and  Hooded  Milk  Pails 104 

53.  A  Model  Dairy,  Showing  Milking  Machine  in  Use 105 

54.  Ordinary  Utensils  Necessary  in  the  Preparation  and  Pasteurization 

of  Milk 107 

55.  Simple  Bottle  Rack 108 

56.  Freeman  Pasteurizer 109 

57.  Improper  Manner  of  Keeping  Milk  in  an  Ice-box no 

58.  Small  Ice-box  for  the  Baby's  Milk 112 

59.  First  Prize  Jersey  Herd,  Canadian  Industrial  Exposition,  1914 113 

60.  A  Herd  of  Holstein  Cows 114 

61.  The  Cleanest  Milk  Comes  from  Cows  in  Pasture 115 

62.  Nursing  Bottles  and  Nipples 117 

63.  Milk  Bottle  and  Cream  Dipper 121 

64.  The  Bottle  Should  be  Held  by  the  Nurse  or  Attendant  Until  It  is 

Empty 125 

65.  The  Wrong  Way  of  Feeding  the  Baby 125 

66.  Screened  House  and  Tent 144 

67.  Simple  Atrophy  or  Marasmus,  in  Child  Eight  Months  Old. 147 

68.  Same  Child  After  Three  Months  of  Proper  Feeding  and  Care 147 

69.  Rectal  Irrigation 148 

70.  Characteristic  Sitting  Position  of  a  Child  With  Rickets 150 


ILLUSTRATIONS  ix 

71.  Bow-legs 150 

72.  Knock-knee  Resulting  from  Rickets 151 

73.  Square  Shaped  Head  Characteristic  in  Severe  Rickets 152 

74.  Pigeon-breast,  Resulting  from  Rickets 153 

75.  Scoliosis  Resulting  from  Rickets 154 

76.  Lordosis,  Resulting  from  Rickets 154 

77.  Kyphosis,  Resulting  from  Rickets 154 

78.  A  Case  of  Scurvy  in  a  Child  of  Six  Months 155 

79.  Simple  Device  for  Securing  a  Specimen  of  Urine  from  Female  Infants  161 

80.  Apparatus  in  Place  for  Securing  Specimen  of  Urine 162 

81.  Method  of  Separating  the  EyeHds 167 

82.  Technic  of  Applying  Ice  Compresses  to  the  Eye  of  an  Infant  with 

Ophthalmia  Neonatorum 167 

83.  Typical  Cretin,  Two  and  one-half  Years  Old 175 

84.  Typical  Cretin 175 

85.  After  a  Six  Month's  Treatment  with  Thyroid  Extract 176 

86.  Club-foot  in  Boy  of  Seven  Years 178 

87.  Same  Case  After  One  Year's  Treatment 178 

88.  Congential  Dislocation  of  the  Hip 179 

89.  Double  Hare-lip  and  Cleft  Palate 180 

90.  Same  Case  One  Year  After  Operation 180 

91.  Prolapse  of  Rectum 192 

92.  Tapeworm,  Showing  Head  and  Segment 195 

93.  Round  Worm 1 95 

94.  Pin-  or  Thread- worm • 196 

95.  Front  View  of  Adenoid  Face 198 

96.  Diagram  Showing  Position  of  Adenoid  Tissue >.  . .  .  199 

97.  Steam  Kettle  for  Use  in  Bronchitis 203 

98.  Temperature  Curve  in  Bronchopneumonia 208 

99.  Temperature  Curve  in  Lobar  Pneumonia '. '.  .  212 

100.  Manner  of  Applying  a  Compress  to  the  Chest 214 

loi.  Facial  Paralysis  Due  to  Injury  at  Birth 216 

102.  Little's  Disease 217 

103.  Microcephalus 219 

104.  Chronic  Internal  Hydrocephalus  in  Child  Twelve  Months  of  Age..  220 

105.  Mongolian  Idiot 221 

106.  Spinal  Bifida  in  Dorsal  Region 222 

107.  Spina  Bifida  in  Lumbar  Region 223 

108.  Limibar  Puncture 227 

109.  Opisthotonos 228 

1 10.  Drop-foot  Resulting  from  Infantile  Paralysis 229 

111.  Deformity  from  Infantile  Paralysis 229 


X  ,  ILLUSTRATIONS 

1 12.  Same  Case  After  One  Year's  Treatment 229 

113.  Eczema  of  Scalp  with  Formation  of  Crusts 237 

1 14.  Impetigo  Contagiosa 238 

115.  Face  Mask  and  Arm  Splints  for  the  Treatment  of  Eczema 239 

116.  General  Vaccination  in  a  Child  with  Eczema 243 

117.  Instruments  for  Intubation  and  Tracheotomy 264 

118.  Position  of  Child  for  Intubation 265 

1 19.  Steam  tent 266 

120.  Tuberculous  Disease  of  the  Vertebrae 269 

121.  Syphilitic  Eruption  on  the  Soles  of  the  Feet  of  New-born  Infants.  272 

122.  Syphilitic  Dactylitis 273 


The  Care  and  Feeding  of 
Infants  and  Children 

CHAPTER  I 

THE  DEVELOPMENT  OF  CHILD-WELFARE  WORK 

FiioM  the  advent  of  scientific  medicine,  which  began  some 
thirty  years  ago,  until  recently,  the  baby  has  been  a  by-product 
in  the  practice  of  obstetrics.  All  the  modern  scientific  methods 
were  lavished  uix)n  the  mother,  both  before  and  after  delivery, 
but  the  infant  was  relegated  to  the  care  of  any  one  who  felt 
interested  or  humane  enough  to  undertake  the  responsibility  of 
its  care. 

When  the  majority  of  the  jxjpulation  lived  on  the  farms  or  in 
small  hamlets,  and  practically  all  mothers  nursed  their  babies, 
the  death  rate  among  infants  during  the  first  year  was  not  large. 
It  was  thought,  by  physicians  and  laity  alike,  to  be  a  question  of 
the  survival  of  the  fittest. 

With  the  development  of  the  great  industrial  centres  and  the 
participation  of  young  girls  and  women  in  factory  work,  the  death 
rate  among  infants  became  appalling.  The  physical  condition  of 
the  women  deteriorated,  and  as  a  result  the  vitality  of  the  chil- 
dren at  birth  was  correspondingly  lowered.  Combined  with  this, 
the  majority  of  these  mothers  weaned  their  babies  at,  or  soon 
after,  birth  and*  fed  them  on  artificial  foods. 

The  wave  of  artificial  feeding  which  passed  over  this  country 
and  Europe  was  materially  aided  by  the  energetic  campaign 
waged  by  the  manufacturers  of  the  diflFerent  patent  foods.  Their 
literature  still  floods  every  home  long  before  the  baby  is  bom. 
The  death  rate  of  infants  in  the  large  cities  rose  to  such  an  extent 
that  in  some  instances  over  50  per  cent,  of  the  infants  succumbed 

1 


2  CARE  OF  INFANTS  AND  CHILDREN 

to  diarrhoeal  affections  during  the  hot  summer  months.  This 
appalhng  condition  led  a  group  of  professional  and  philanthropic 
people  to  undertake  a  crusade  with  the  object  of  determining  and 
removing  the  causes  as  far  as  possible. 

It  was  assumed  that  the  large  death  rate  was  due  to  infected 
milk  and  utensils,  and  to  the  fact  that  cow's  milk  was  not  prop- 
erly modified  for  infants.  All  the  attention  was  therefore  directed 
to  improving  the  milk  supply  and  to  modifying  milk  according  to 
prescribed  percentages.  Milk  stations  were  started  in  all  large 
cities,  with  a  clinic  in  connection,  where  the  babies  were  ex- 
amined by  the  physicians  and  the  proper  formulas  prescribed  and 
prepared.  This  resulted  in  a  very  large  reduction  in  the  infant 
mortality,  especially  among  the  very  poor  in  the  crowded  tene- 
ment districts  and  in  institutions.  During  this  time  a  few  really 
scientific  men  were  laying  the  foundation  of  modern  pediatrics. 
It  was  observed  by  such  men  as  Jacobi  and  Heubner  that  there 
was  a  large  number  of  children,  perfectly  normal  at  birth,  who 
were  fed  on  the  best  cow's  milk  available,  modified  in  exact 
percentages  of  proteid,  fat  and  sugar,  who  did  badly,  and  dur- 
ing the  hot  weather  often  succumbed. 

From  the  volumes  of  new  work  which  have  been  written  on 
pediatrics  during  the  past  few  years  the  following  important 
facts  may  be  mentioned : 

1.  Every  mammal,  including  the  human,  has  a  milk  peculiar 
to  its  own  kind  and  needs,  and  if  the  death  rate  in  infants  is  to 
be  lowered  beyond  a  certain  point,  infants  must  be  fed  on  human 
milk. 

2.  Ninety  per  cent,  of  mothers  can  nurse  their  babies  in 
whole  or  in  part,  the  majority  of  failures  being  due  to  errors  in 
proper  living  and  technic. 

3.  Many  times  when  infants  do  not  thrive  at  the  breast  the 
cause  may  be  found  in  inherited  weakness  and  disease. 

4.  Neither  cow's  milk  nor  any  other  food  can  be  modified  to 
even  approximate  mother's  milk,  even  when  the  percentages  of 
the  different  elements  are  the  same. 


CHILD-WELFARE  WORK  3 

5.  The  average  cow's  milk  is  not  a  safe  food  for  children 
without  pasteurization  or  boiling. 

6.  The  fat  of  cow's  milk  is  more  difficult  of  digestion  than 
the  proteid. 

7.  Many  of  the  diarrhoeal  disorders  of  infancy  are  not  due 
to  infected  milk,  as  was  supposed,  but  to  overfeeding,  combined 
often  with  excessive  heat  and  clothing. 

8.  The  infant  is  not  a  miniature  adult,  as  was  formerly  sup- 
f>osed,  but  has  a  physiology  of  its  own.  Its  unstable  and  rapidly 
developing  organism  requires  food  especially  adapted  to  its  needs 
and  an  amount  out  of  all  proportion  to  its  age  and  size. 

These  facts  are  mentioned  to  show  that  the  old  haphazard  way 
of  caring  for  children  is  a  thing  of  the  past,  and  that  modem 
pediatrics  rests  upon  a  scientific  basis  as  much  as  does  the 
science  of  obstetrics,  surgery,  or  medicine. 

Whatever  progress  is  made  in  the  field  of  preventive  medi- 
cine will  be  by  the  education  of  the  public  along  these  lines. 

People  exercise  great  care  about  what  they  feed  their  domestic 
animals,  and  at  the  same  time  allow  their  children  to  eat  any- 
thing they  want,  and  at  any  time  they  want  it. 

For  the  properly  trained  nurse  the  subject  of  child  welfare 
offers  a  field  capable  of  greater  fundamental  service  to  humanity 
than  almost  any  other.  She  begins  her  service  during  the  preg- 
nancy of  the  mother.  She  sees  under  what  kind  of  social  and 
hygienic  conditions  the  prospective  mother  is  living,  and  notices 
the  character  of  her  general  nutrition  and  the  kind  of  food  she  is 
having.  She  sees  whether  the  nipples  are  inverted,  and  if  they 
are  she  undertakes  their  proper  development.  She  sees  that  a 
specimen  of  urine  is  sent  at  proper  intervals  to  the  physician  for 
examination,  and  in  every  way  possible  she  prepares  the  pros- 
pective mother  to  assurne  her  new  duties  with  a  proper  spirit  of 
responsibility. 

After  delivery  she  sees  that  the  best  interests  jof  the  baby,  as 
well  as  those  of  the  mother,  are  properly  conserved. 

While  the  nurse  is  in  the  house  she  has  a  rare  opportunity  to 


4  CARE  OF  INFANTS  AND  CHILDREN 

observe  and  advise  about  the  diet  and  habits  of  the  older  children. 

Even  among  the  very  poor  and  ignorant,  it  is  surprising  to 
see  how  quickly  a  crowd  of  ill-fed  children  can  be  transformed 
by  the  weekly  visits  of  the  child-welfare  nurse.  Such  a  family 
becomes  a  model  for  the  neighborhood,  with  the  result  that  the 
physical  and  moral  tone  of  the  community  is  distinctly  improved. 

The  child-welfare  nurse  should  be  well  informed,  not  only  on 
the  care  and  feeding  of  children,  but  also  in  the  field  of  social 
service.  In  order  to  be  successful  she  must  be  both  resourceful 
and  tactful.  In  poor  families  she  must  learn  to  make  the  most  of 
a  limited  equipment  in  the  preparation  and  care  of  the  food. 
She  must  be  prepared  to  advise  the  family  how  to  procure  food 
of  the  greatest  value  with  the  least  amount  of  money. 

She  will  meet  prejudices  at  every  hand  which  have  been 
handed  down  for  many  generations,  many  of  which  have  no 
foundation  in  fact,  and  may  be  actually  harmful.  It  is  not  suffi- 
cient to  say  that  these  things  are  wrong — sound  reasons  must  be 
given  and  advanced  in  such  a  way  that  they  will  be  accepted  and 
acted  upon. 

Much  of  the  quackery  in  medicine  has  been  made  possible  be- 
cause of  the  mysticism  which  has  been  thrown  around  it.  The 
time  has  come  to  take  the  public  into  our  confidence  and  show 
them  what  they  may  rightfully  expect  of  themselves  and  the 
medical  profession. 

The  Nurse  and  Her  Equipment 

A  nurse  to  be  successful  in  the  care  of  children  should  have 
certain  natural  qualifications.  She  should  have  a  sanguine  tem- 
perament and  be  possessed  of  endless  patience.  To  nurse  a  sick 
baby  back  to  health  frequently  takes  weeks  or  months  of  gentle, 
patient,  intelligent  handling.  In  the  care  of  sick  infants  the 
nurse  must  realize  that  she  is  dealing  with  an  individual  which 
is  absolutely  helpless.  A  baby  is  not  a  miniature  adult,  as  was 
fomierly  supposed,  but  has  a  physiology  of  its  own,  and  its 
chances  for  recovery  often  depend  more  upon  the  nurse's  care 
than  on  any  other  factor. 


CHILD- WELFARE  WORK  5 

It  is  not  necessary  to  spoil  children  because  they  are  ill,  so  that 
tenderness  must  be  qualified  by  firmness.  It  is  necessary  that  the 
nurse  have  absolute  confidence  in  her  ability  to  control  her 
patient. 

Since  young  children  cannot  talk,  it  is  imperative  that  the 
nurse  observe  carefully  all  symptoms  and  learn  to  know  their 
significance. 

It  must  be  remembered  that  there  are  certain  movements  and 
expressions  which  are  characteristic  of  the  normal  infant.  These 
must  be  carefully  studied,  as  it  is  necessary  to  know  the  normal 
to  be  able  to  appreciate  the  abnormal. 

The  character  and  expression  of  the  eyes  are  of  the  greatest 
importance  in  determining  whether  a  child  is  sick  or  well.  In 
health  there  is  an  intelligent  response  when  the  baby  is  spoken 
to,  or  when  bright  objects  are  placed  where  they  may  be  seen. 
On  the  other  hand,  a  vacant,  staring  expression  of  the  eyes  is 
characteristic  of  an  intestinal  intoxication,  as  is  the  sudden  onset 
of  a  strabismus  or  an  inequality  of  the  pupils  of  an  intracranial 
pressure,  which  often  signifies  the  presence  of  a  meningitis. 

Any  lack  of  uniformity  of  movements  of  the  corresponding 
muscles  on  the  two  sides  should  be  carefully  noted. 

The  appearance  and  feeling  of  the  normal  skin  is  in  great 
contrast  to  the  dry,  pale,  non-elastic  skin  in  simple  atrophy,  the 
hot,  dry  skin  during  a  fever,  or  the  cold,  clammy  skin  during 
collapse. 

The  normal  appearance  of  the  tongue,  lips,  and  mucous  mem- 
brane of  the  mouth  should  be  carefully  observed,  so  that  any 
departure  from  the  normal,  in  the  way  of  dryness  or  coating,  may 
be  promptly  recognized. 

The  cry  of  infants  is  an  interesting  and  profitable  study. 
There  is  no  doubt  that  there  are  certain  cries  which  are  called 
forth  by  certain  definite  conditions.  For  example,  the  sharp  cry 
which  occurs  in  meningitis  may  be  said  to  be  fairly  characteristic, 
as  is  the  loud,  piercing  cry  which  accompanies  severe  pain,  as 
when  the  baby  has  aeute*  indigestion  or  its  skin  is  pierced  by  a 


6  CARE  OF  INFANTS  AND  CHILDREN 

safety-pin.  On  the  other  hand,  infants  cry  loudly  and  con- 
tinuously and  at  about  the  same  tempo  when  they  have  colic, 
when  they  are  hungry,  or  when  they  are  spoiled.  It  is,  therefore, 
not  safe  to  base  one's  diagnosis  on  the  cry  alone  without  a  careful 
analysis  of  all  symptoms.  The  diagnosis  of  hunger  is  too  often 
made  because  the  baby  cries  and  sticks  its  fingers  in  its  mouth, 
when  in  reality  it  is  already  overfed  or  wishes  to  be  rocked  or 
carried  about. 

Combined  with  an  analysis  of  crying  should  go  a  careful 
observation  of  the  stools.  If  a  child  cries  much  and  the  stools  are 
of  a  good  character  and  there  is  no  vomiting,  and  the  baby  is 
gaining  properly  in  weight,  it  is  presumably  not  having  colic,  but 
is  spoiled.  On  the  other  hand,  if  the  baby  cries  much  and  the 
stools  are  large  and  curdy,  or  green,  it  is  presumably  not  crying 
from  hunger  but  from  colic  due  to  overfeeding. 

Great  judgment  is  therefore  necessary  on  the  part  of  the 
nurse.  To  give  a  baby  a  second  feeding  of  milk  after  the  onset 
of  acute  vomiting  or  diarrhoea  is  often  to  prolong  the  condition 
for  days  or  weeks,  when  a  complete  rest  for  one  or  two  feedings 
instituted  at  once  might  have  restored  the  digestive  tract  to 
normal. 

Obstetrical  nurses,  and  those  who  intend  to  specialize  in  child 
nursing,  should  take  a  special  course  of  training  for  a  few  months 
in  a  children's  hospital,  or  should  attach  themselves  to  a  child- 
welfare  clinic. 

Social  service  nurses  and  those  who  intend  doing  school  or 
child-welfare  work  should  not  only  have  special  training,  but  do 
a  large  amount  of  supplementary  reading  along  the  particular 
lines  in  which  they  are  specializing.  Standard  text-books  may  be 
found  in  the  library  of  the  local  medical  society. 

Tn  the  care  of  an  older  child,  of  from  four  years  on,  and 
particularly  during  convalescence,  the  question  of  keeping  him 
occupied  and  happy  is  of  great  importance.  An  intelligent,  re- 
sourceful nurse  should  aim  not  simply  to  amuse  a  child,  but  to 
have  him  intelligently  occupied.     Reading  aloud  from  books. 


CHILD-WELFARE  WORK  7 

carefully  selected  with  reference  to  the  condition  and  tempera- 
ment of  the  individual  case,  is  a  pleasant  and  profitable  way  of 
spending  part  of  each  day.  Kindergarten  activities,  such  as 
cutting  out  pictures,  pasting,  sewing,  drawing,  or  painting,  are 
quiet  occupations  of  great  interest  to  the  average  child.  There 
are  in  every  public  library  suggestive  books  on  child  nature  and 
kindergarten  methods  and  pastimes  which  would  undoubtedly  be 
stimulating  and  useful  to  the  ambitious  nurse  who  wishes  the 
best  possible  equipment  for  her  work. 


CHAPTER  II 

ANATOMY  AND  PHYSIOLOGY 

The  body  of  the  infant  at  birth  has  the  same  general  struc- 
ture, and  contains  essentially  the  same  organs,  as  that  of  the 
older  child  or  adult.  There  are,  however,  some  differences,  both 
in  the  anatomy  and  physiology,  which  should  be  carefully  noted. 

The  Skeleton 

The  skeleton  or  bony  framework  of  the  new-born  is  made  up 
largely  of  cartilage,  which  in  comparison  with  bone  is  soft  and 
pliable  and  is  very  liable  to  deformities  and  fractures,  especially 
of  the  greenstick  variety.  Later,  as  the  child  reaches  the  age  of 
adolescence,  the  cartilage,  by  the  multiplication  of  the  bone  cells 
and  the  deposition  of  lime  salts,  is  transformed  into  bone. 

Epiphyses. — The  long  bones  develop  (in  length)  from 
centres  called  epiphyses  which  are  easily  separated  from  the 
shaft.  Injury  to  the  epiphyses  may  result  in  shortening  of  the 
bone,  from  lack  of  development. 

The  different  bones  are  held  in  apposition  by  fibrous  ligaments 
which  in  some  cases  hold  the  opposing  bones  rather  firmly  to- 
gether, while  in  others  they  act  as  hinges,  allowing  great  free- 
dom of  motion,  some  in  all  directions,  as  in  the  case  of  the 
shoulder-joint,  while  in  others — the  knee-joint,  for  example- — 
there  is  freedom  only  in  anteroposterior  movements. 

THE  SKULL 

Sutures. — The  bones  of  the  skull  in  infants  are  so  loosely 
held  together  that  there  is  frequently  considerable  overriding 
of  the  opposing  edges — so  much  so  that  at  birth  there  may  be  a 
8 


ANATOMY  AND  PHYSIOLOGY  9 

marked  change  in  the  shape  of  the  head.^  The  spaces  separating 
the  opposing  edges  of  the  bones  in  the  skull  are  called  sutures 
(Fig.  i).  These  gradually  disappear,  the  two  bones  becoming 
essentially  one  by  means  of  ossification  at  about  the  eighteenth 
to  twentieth  month. 

FoNTANELLES. — The  large  four-sided  opening  at  the  junction 
of  the  two  frontal  and  two  parietal  bones  is  called  the  anterior,  or 


/ 


\ 


Fig.   1. — Sutures 


olles. 


large  fontanelle,  and  the  smaller  triangular  opening  at  the  junc- 
tion of  the  occipital  and  parietal  bones  is  known  as  the  posterior, 
or  small,  fontanelle  (Fig.  i).    The  small  fontanelle  closes  nor- 

*  An  oedematous  condition  of  the  scalp,  due  to  pressure  during  birth, 
is  known  as  caput  succedancum.  It  disappears  by  absorption  in  a  few- 
days.  Haematomas  or  blood  tumors  under  the  scalp,  due  to  injury 
from  forceps,  are  common.  They  should  be  left  alone  and  never  opened, 
as  serious  infection  may  result.  They  disappear  by  absorption  in  a  week 
or  ten  days   (Fig.  2). 


lO  CARE  OF  INFANTS  AND  "CHILDREN 

nially  within  the  first  year,  while  the  large  fontanelle  closes 
normally  from  the  fifteenth  to  the  twentieth  month.  When  it 
remains  open  beyond  the  second  year  it  indicates  thcipresence  of 
rickets  or  some  other  abnormal  condition. 

Progressive  widening  of  the  fontanelles  and  sutures  usually 
indicates  the  presence  of  hydrocephalus. 

The  Jaws. — The  jaws  of  the  young  infant  as  compared  with 
those  of  the  older  child  or  adult  are  markedly  undeveloped. 
These  differences,  together  with  the  character  of  the  sutures  and 
fontanelles,  are  well  illustrated  by  the  accompanying  drawings. 
The  teeth,  although  in  the  jaws  at  birth,  are  undeveloped.    It  is 

this  later  development  which  con- 
stitutes the  essential  difference  in 
appearance  between  the  jaws  of 
the  infant  and  those  of  the  adult 
(Figs.  3  and  4). 

Sinuses. — "  The    maxillary 
sinus  or  antrum  of  Highmore  and 
the  mastoid  antrum  are  the  only 
cavities    which    exist    at    birth. 
Fig.  2.— Cephaihaematoma.  They  are  both  small,  and  increase 

much  in  size  as  the  child  grows  older.  The  mastoid  antrum  in 
relation  to  the  size  and  age  of  the  child  is  relatively  large.  The 
frontal,  ethmoidal,  and  sphenoidal  sinuses  appear  about  the 
seventh  year,  but  it  is  not  until  puberty  that  they  really  begin  to 
develop.  The  mastoid  cells  also  appear  at  puberty  and  increase 
with  age." 

THE    THORAX 

Character  and  Shape. — The  thorax,  which  contains  the 
lungs,  heart  and  the  accompanying  great  vessels,  differs  chiefly 
from  that  of  the  adult  in  its  shape  and  in  the  soft  character  of 
the  bones  which  form  its  walls.  The  shape  of  the  infant's  chest 
is  relatively  narrower  at  the  top  than  in  the  adult  and  wider  at 
the  bottom,  having  something  the  shape  of  a  cone  with  its  apex 
at  the  base  of  the  neck  (Figs.  5  and  6) .    The  anteroposterior  and 


ANATOMY  AND  PHYSIOLOGY 


II 


transverse  diameters  are  nearly  equal  in  the  infant,  while  in  the 
adult  the  transverse  is  greater  by  about  one-quarter.  The  bones 
of  the  chest  wall  are  made  up  largely  of  cartilage  and  are  con- 


FiG.  3.— Skull  of  adult. 


Fig.  4. — Skull  of  infant. 


sequently  very  prone  to  changes  in   shape.     Since  the  act  of 
breathing  is  dependent  upon  the  action  of  the  muscles  in  elevat- 


FiG.  5.— Chest  of  adult. 


Fig.  6. — Chest  of  infant. 


ing  and  lowering  the  ribs,  together  with  action  of  the  diaphragm, 
any  deformity  of  the  bones  of  the  thorax  is  a  serious  menace  to 
health.     Such  deformity  may  result  from  rickets,  interference 


12 


CARE  OF  INFANTS  AND  CHILDREN 

in  breathing  through  the  nose,  enforced  posi- 
tions which  the  infant  is  not  able  itself  to 
maintain,  as  well  as  by  diseases  of  the  thoracic 
organs  themselves. 


THE   SPINAL    CORD 

The  spinal  column  is  made  up  of  thirty- 
three  segments,  called  vertebrae  (Fig.  7).  In 
the  infant  these  segments  consist  largely  of 
cartilage  placed  one  upon  the  other  and  sepa- 
rated by  connective  tissue.  The  different 
vertebrae  are  held  together  by  ligaments 
which  allow  a  large  range  of  flexibility  in  all 
directions.  The  vertebral  column  is  divided 
anatomically  into  five  parts,  namely :  ( i ) 
Seven  cervical;  (2)  twelve  dorsal ;  (3)  five 
lumbar;  (4)  five  sacral;  (5)  four  coccygeal. 

The  cervical  vertebrcc  are  those  of  the 
neck,  the  first  one  articulating  with  the  base 
of  the  skull  and  usually  called  the  atlas. 

The  dorsal  vertebrcc  represent  the  thoracic 
portion  to  which  the  ribs  are  attached. 

The  lumbar  vertebrcc  represent  the  ab- 
dominal portion. 

The  sacral,  which  in  the  adult  become 
ossified,  leaving  no  separation  between  the 
individual  vertebrae,  form  the  posterior  por- 
tion of  the  pelvis. 

The  coccygeal  are  the  most  rudimentary 
parts  of  the  vertebral  column  and  represent 
what  in  the  animal  is  the  tail.  Occasionally 
the  last  segment  of  the  coccyx  becomes  loos- 
ened and,  owing  to  the  pressure  of  sitting 
upon  it,  an  inflammation  is  set  up  which  is  ex- 
tremely painful,  sometimes  necessitating  surgical  interference. 


Fig.  7. — Spinal  column 
showing  natural  curves. 


ANATOMY  AND  PHYSIOLOGY  13 

THE  SPINAL   CANAL 

The  canal  extends  throughout  the  spinal  column  to  the  end  of 
the  sacral  vertebrre.  The  spinal  cord,  which  is  contained  in  the 
canal,  and  which  serves  to  protect  it  from  injury,  does  not  extend 
beyond  the  lumbar  vertebrae  and  there  terminates  in  a  bundle  of 
nerves  known  as  the  cauda  equina. 

Foramina. — Between  the  vertebrae,  throughout  the  length  of 
the  spinal  column,  are  lateral  openings  called  foramina,  which 
transmit  the  nerve  branches  to  and  from  the  spinal  cord.  The 
spinal  column  in  the  young  child  is  soft  and  poorly  supported  by 
muscles,  so  that  the  natural  curves  are  liable  to  be  exaggerated, 
producing  deformities.  An  acute  bending  of  the  spine  posteriorly 
is  called  kyphosis,  an  exaggerated  bending  forward,  lordosis,  and 
a  lateral  curvature,  scoliosis. 

Deformities  from  Rickets  and  Tuberculosis. — ^These  de- 
formities may  result  either  from  malpositions  or  from  diseases 
such  as  rickets,  although  the  most  common  cause  of  such  a  de- 
formity is  a  tuberculous  involvement  of  the  bodies  of  the 
vertebrae.  ^ 

The  Heart  and  Circulation  of  the  Blood 
In  the  foetus  the  heart  begins  to  beat  and  send  blood  through 
the  body  as  early  as  the  second  month. 

Before  birth  the  blood  must  pass  through  the  cord  to  the 
placenta  of  the  mother,  where  it  gives  up  its  carbon  dioxide  and 
other  waste  matter,  becomes  oxygenated,  returning  through  the 
umbilical  veins  to  be  distributed  by  the  heart  throughout  the 
body.  The  circulatory  systems  of  the  mother  and  foetus  are 
quite  distinct,  the  blood  of  one  coming  into  contact  with  that  of 
the  other  only  through  the  vessel  walls  of  the  placenta. 

At  birth,  as  soon  as  the  cord  has  been  tied,  the  blood,  instead 
of  being  diverted  to  the  placenta,  must  all  pass  through  the  lungs 
to  receive  oxygen.  It  is,  therefore,  necessary  that  the  foramen 
ovale,  as  well  as  the  ductus  arteriosus  and  ductus  venosus,  should 
close  permanently  (Figs.  8  and  9) .    When  one  of  these  openings 


>^.2J^^ 


DESCEh; 
VENA  ■ 
CAVA 


ARTERIAL  BLOOD 
|v%^      VENOUS     BLOOD 

Fig.  8. — Diagram  of  infant's  circulation  before  birth. 


^koWJJM^ 


DESC 
VENA, 
CAVA^ 


ARTERIAL  BLOOD 


MM     VENOUS     BLOOD 
Fig.  9. — Diagram  of  infant's  circulation  after  birth. 


l6  CARE  OF  INFANTS  AND  CHILDREN 

remains  patent,  as  occurs  in  a  small  percentage  of  cases,  oxygena- 
tion is  interfered  with.  Such  cases  usually  succumb  in  infancy 
or  early  childhood.  The  one  form  of  congenital  heart  which 
results  in  what  is  known  as  a  "  blue  baby  "  may  be  due  to  ob- 
structions in  the  pulmonary  valve,  or  to  some  constriction  in  the 
pulmwnary  artery.  The  blue  (cyanotic)  condition  of  the  skin 
and  mucous  membranes  is  due  to  improper  oxygenation  of  the 
blood. 

Position  of  the  Heart. — The  heart  occupies  much  the  same 
position  as  in  the  adult.  It  is,  however,  somewhat  higher  and 
more  horizontal  and  further  to  the  left.  In  the  first  four  years 
the  apex  beat  is  usually  palpable  slightly  to  the  left  of  the  nipple 
line,  from  the  fourth  to  the  twelfth  year,  in  the  nipple  line,  and 
after  the  thirteenth  year  it  is  usually  well  within  the  nipple  line. 

The  Apex  Beat. — During  the  first  year  the  apex  impulse 
may  usually  be  felt  in  the  fourth  intercostal  space.  After  the 
second  year  it  may  be  found  either  in  the  fourth  or  fifth  inter- 
space, and  after  the  seventh  or  eighth  year  it  is  normally  in  the 
fifth  intercostal  space.  Any  deformity  of  the  chest  wall,  how- 
ever, will  change  their  relative  positions. 

Frequency  of  the  Heart  Beat. — At  birth  the  heart  beats 
from  one  hundred  and  twenty  to  one  hundred  and  thirty  times 
a  minute. 

This  gradually  diminishes  as  the  child  grows  older,  until  the 
age  of  adolescence,  after  which  the  average  rate  under  normal 
conditions  remains  about  the  same  throughout  life. 

Variation  Under  Normal  Conditions. — Great  variation 
occurs  in  the  rate  of  the  heart,  depending  upon  mental  and  bodily 
activity.  If  the  child  is  crying  or  nervous,  the  pulse  is  usually 
very  rapid,  and  it  is  also  markedly  increased  in  frequency  fol- 
lowing a  meal.  Care,  therefore,  should  be  taken  to  obtain  the 
pulse  rate  when  the  child  is  quiet,  or.  better,  when  asleep.  Dur- 
ing sleep  the  pulse  is  often  irregular. 

According  to  numerous  observers,  the  pulse  rate  during  sleep 
for  dififerent  ages  is  as  follows : 


ANATOMY  AND  PHYSIOLOGY  17 

Six  to   twelve   months    105-120 

Two  to  six  years   90-1  lO 

Seven  to  ten  years   80-  90 

Eleven  to  fourteen  years  72-  85 

Irregularity. — Irregularity  of  the  pulse  rate  is  frequent  in 
children,  but  has  no  particular  significance  during  health.  It 
may,  however,  have  grave  significance  during  the  course  of  such 
diseases  as  diphtheria.  The  taking  of  the  pulse  in  children  is 
rarely  accurately  done. 

Manner  of  Taking  the  Pulse. — Unless  a  child  is  very 
docile,  it  is  usually  impossible  to  have  him  keep  still  long  enough 
during  waking  hours  to  take  a  radial  pulse  accurately.  It  is  usu- 
ally much  easier  to  take  the  pulse  from  the  carotid  artery  in  the 
neck  or  from  the  temporal  just  in  front  of  the  ear.  It  should  be 
done  by  making  gentle  pressure  with  the  tips  of  the  fingers,  for, 
if  too  great  pressure  is  used,  the  circulation  will  be  shut  ofif,  and, 
too,  it  is  not  improbable  that  the  nurse's  pulse  may  be  counted 
instead  of  the  child's. 

Functional  Disturbances. — Owing  to  the  rapid  growth  of 
the  heart  in  young  children,  it  is  not  infrequent  for  functional  dis- 
turbances of  the  circulation  to  result.  It  is,  however,  always  im- 
portant to  determine  whether  they  are  functional  or  organic,  as  in 
both  cases  the  future  well-being  of  the  child  may  depend  upon  the 
care  it  receives.      (See  chapter  on  Heart  Aflfections,  p.  235.) 

Lymphatic  System 

*♦* 

"  The  lymphatic  system  begins  in  the  microscopic  crevices  be- 
tween the  cells  and  fibres  of  almost  all  tissue."  They  are  the  re- 
ceptacles of  the  fluids  which  exude  from  the  adjacent  tissues. 
They  communicate  very  freely  among  themselves  and  empty  into 
the  larger  lymphatic  vessels. 

Lacteals. — The  outer  surface  of  the  body  is  rich  in  lymphatic 
vessels,  as  well  as  the  inner  tissues.  The  lymphatics  in  the  in- 
testinal walls  do  not  diflfer  essentially  from  the  others,  except  that 
during  digestion  they  carry  the  chyle,  which  resembles  milk  in 
2 


l8  CARE  OF  INFANTS  AND  CHILDREN 

appearance.    They  are  therefore  frequently  called  lacteal  vessels. 

Lymphatic  Ducts. — Ultimately  the  lymphatic  vessels  empty 
their  contents  into  the  veins  at  the  hase  of  the  neck,  through  two 
openings  known  as  the  right  and  the  left  lymphatic  ducts. 

Lymphatic  Nodes. — Scattered  through  the  lymphatic  chan- 
nels are  lymphatic  nodes  or  lymphatic  glands,  which  serve  as  the 
filters,  and,  figuratively  speaking,  are  the  police  stations  of  the 
body. 

Any  foreign  substances,  such  as  bacteria,  which  enter  the 
tissues  are  taken  up  by  the  lymphatics  and  carried  to  the  lymphatic 
glands,  where  they  are  either  destroyed,  or  the  gland  structure  is 
destroyed  or  at  least  undergoes  increase  in  size  and  sometimes 
breaks  down,  forming  an  abscess. 

In  many  children  the  lymphatic  glands  of  the  neck  are  always 
enlarged,  as  well -as  the  pharyngeal  tonsils  and  the  post-nasal 
lymphatic  tissues,  which,  when  much  increased  in  size,  are  called 
adenoids.  Enlarged  glands  in  the  neck  are  frequently  due  to 
infections  from  the  tonsils  and  adenoids,  although  in  some  chil- 
dren a  moderate  enlargement  may  be  normal  (lymphatic  dia- 
thesis). 

Respiratory  System 

The  act  of  breathing  is  automatic,  although  to  some  degree  it 
is  under  the  control  of  the  will. 

It  is  probable  that  the  accumulation  of  waste  products  in  the 
blood  acts  on  the  nerve  centres,  which  in  turn  act  upon  the 
muscles  of  respiration,  resulting  in  an  elevation  of  the  chest  wall 
and  retraction  downward  of  the  diaphragm,  thereby  tending  to 
create  a  vacuum.  The  air  then  rushes  in  through  the  upper  air 
passages  and  bronchi,  inflating  the  air  vesicles,  and  coming  into 
intimate  relation  with  the  blood  through  the  thin  walls  of  the 
capillaries.  By  this  means  the  blood  gives  up  its  waste  products, 
carbon  dioxide  and  carbon  monoxide,  and  takes  up  the  neces- 
.sary  amount  of  oxygen. 

No.SE  Breathing. — ^The  natural  channel  through  which  the 


ANATOMY  AND  PHYSIOLOGY 


19 


air  should  pass  to  the  bronchi  is  the  nose.  The  air  is  thereby 
filtered  to  some  extent  by  the  moist  mucous  membrane  and  is  at 
the  same  time  warmed  before  it  enters  the  lungs. 

Results  of  Mouth  Breathing. — Any  obstruction  to  the 
nasal  passage  making  it  necessary  to  breathe  through  the  mouth 
is  liable  to  be  followed  by  some  inflammation  of  the  air  passages, 
pharyngitis,  laryngitis,  or  bronchitis,  and  there  is  prone  to  be 
more  or  less  cough.  Some  deformity  of  the  chest  wall  also  re- 
sults from  mouth-breathing,  particularly  of  the  lower  anterior 
portion.  This  deformity  is  usually  manifested  by  a  transverse 
groove  known  as  Harrison's  groove. 

Abdominal  Breathing. — The  breathing  in  young  infants  is 
largely  abdominal  in  character,  that  is,  the  elevation  or  retraction 
of  the  diaphragm  results  in  sufficient  air  entering  the  lungs  with- 
out much  chest  expansion.  This  is  a  frequent  cause  of  alarm  to 
young  mothers,  who,  when  the  child  is  asleep,  suddenly  notice 
that  there  is  little  or  no  movement  of  the  chest-wall.  By  un- 
covering the  abdomen  in  such  cases  the  movement  of  the  ab- 
dominal wall  may  be  readily  seen. 

Thoracic  Breathing. — As  the  infant  becomes  older  the  ab- 
dominal breathing  diminishes  and  the  chest  breathing  increases. 

Frequency  of  Respiration. — The  frequency  of  the  breath- 
ing in  young  infants  is  at  birth  from  thirty  to  forty  per  minute. 
As  the  child  grows  older  it  gradually  diminishes,  until  at  adoles- 
cence it  varies  from  eighteen  to  twenty  per  minute. 

The  frequency  of  respiration  is,  of  course,  markedly  in- 
creased by  exercises  as  well  as  by  pathological  conditions.  There 
are,  however,  certain  cerebral  affections  which  produce  a  slowing 
of  the  respiration.    This  will  be  taken  up  under  "  Meningitis.'' 

Rhythm  of  Breathing. — The  rhythm  of  the  breathing  in 
young  children  is  liable  to  be  irregular,  particularly  during  sleep, 
and  may  at  times  assume  something  of  the  Chcyne-Stokes  char- 
acter. This  is  also  frequently  a  source  of  anxiety  to  young 
mothers  as  well  as  to  all  members  of  the  household. 


20  CARE  OF  INFANTS  AND  CHILDREN 

The  13igesti\i<:  Tract 
The  digestive  tract  may  be  divided  anatomically,  as  follows : 
The  mouth  and  pharynx  ;  the  asophagus  ;  the  stomach  ;  the  small 
intestine ;  the  large  bowel  or  colon ;  a  group  of  accessory  glands, 
including  the  salivary  glands,  liver,  and  pancreas. 

THE    MOUTH 

Sucking. — In  the  young  infant  the  chief  function  of  the 
mouth  is  the  act  of  sucking,  which  is  a  complicated  procedure, 
requiring  the  joint  action  of  the  lips,  jaws,  tongue,  roof  of  the 
mouth,  and  cheeks. 

The  Salivary  Glands. — ^The  secretions  of  the  salivary  glands 
are  active  at  birth  and  have  a  feeble  digestive  action  on  starches 
which  continues  for  some  time  after  the  food  has  reached  the 
stomach.  The  mixture  of  the  saliva  with  the  milk  helps  the 
further  action  of  the  gastric  secretions. 

The  oesophagus  requires  little  attention,  save  as  the  site  of  cer- 
tain abnormalities,  to  be  considered  later. 

THE   STOMACH 

The  stomach  at  birth  lies  obliquely  in  the  left  side  of  the  al)- 
domen,  directly  under  the  diaphragm,  extending  from  left  to 
right.  As  age  increases  its  position  becomes  more  horizontal. 
The  stomach  at  birth  is  nearly  cylindrical,  but  the  fundus  in- 
creases in  size  very  rapidly  during  the  first  year  but  does  not 
reach  its  full  development  until  quite  late  in  childhood. 

The  following  is  the  average  amount  of  food  taken  at  a  meal, 
at  the  different  ages,  as  observed  by  weighing  before  and  after 
nursing : 

At  birth    '/>-!  ounce 

At  one  week   z  ounces 

At  two  weeks   2]^  ounces 

At  four  weeks    3-4  ounces 

At  eight   weeks    4-5  ounces 

At  three  months    5-6  ounces 

At  six  months    6-7  ounces 

At  nine    months    7-8  ounces 

At  twelve  months    8  ounces 


ANATOMY  AND  PHYSIOLOGY  21 

These  figures  for  the  first  .weeks  after  birth  are  greater  than 
those  given  by  many  authorities,  but  they  may  be  verified  by 
weighing  the  baby  before  and  after  nursing,  when  it  will  be 
found  that  the  quantity  received  at  different  times  varies  greatly, 
but  many  times,  particularly  in  the  early  morning  nursings,  is 
greatly  in  excess  of  what  has  been  considered  the  stomach 
capacity  at  that  age.  These  figures  were  obtained  by  weighing  at 
four-hour  intervals — five  nursings  in  twenty-four  hours. 

Functions  of  the  Stomach. — The  stomach  in  the  new-born 
infant  does  not  play  a  very  important  role  in  the  digestion  of  the 
food,  but  acts  rather  as  a  reservoir.  It  is  true  there  are  certain 
active  ferments  capable  of  digesting  proteid,  and  even  fat  -  and 
starch  to  some  slight  extent,  but  the  large  part  of  the  digestion 
takes  place  in  the  small  intestine.  The  proteid  is  acted  upon  in 
the  stomach  by  the  pepsin  in  the  presence  of  hydrochloric  or 
lactic  acid. 

Pepsin  and  both  hydrochloric  and  lactic  acid  are  found  in 
the  stomach  at  birth.  Pepsin  is  capable  of  transforming  proteid 
into  peptone  in  the  presence  of  the  amount  of  these  acids 
secreted.^ 

Coagulation  of  Milk  by  the  Rennet. — The  coagulation 
of  the  milk  in  the  stomach  occurs  as  a  result  of  the  action  of  the 
rennet  ferment.  Mothers'  milk  coagulates  in  a  light  flocculent 
precipitate,  while  cow's  milk,  unless  boiled  or  diluted  with  some 
alkali  or  gruel,  coagulates  in  dense  curds. 

Muscular  Contraction  of  the  Stomach. — The  small  end 
of  the  stomach,  called  the  pylorus,  is  closed  by  circular  muscular 
fibres  which  relax  at  intervals,  allowing  some  of  the  stomach 
contents  to  pass  into  the  duodenum.  The  milk  begins  to  leave 
the  stomach  almost  immediately,  its  progress  being  accelerated 
by  the  rhythmic  contractions  of  the  stomach  walls.  The  upper 
opening  of  the  stomach,  or  cardiac  sphincter,  is  but  feebly  closed 

*  Sedgwick,  Jahrbuch  fiir  Kinderheilkunde,  June,  1906. 

*  Ramsey,  Walter  R.,  Jahrbuch  fiir  Kinderheilkunde,  August,  1908; 
Archives  of  Pediatrics,  August,  1908. 


22  CARE  OF  INFANTS  AND  CHILDREN 

in  the  infant,  so  that  regurgitation  of  food  occurs  readily  from 
increased  pressure  or  change  of  position. 

Time  REyuiKKO  to  Empty  the  Stomach. — The  time  neces- 
sary under  normal  conditions  for  the  infant  stomach  to  empty 
itself  depends  upon  the  character  of  the  food  and  the  quantity 
given.  The  stomach  of  the  average  healthy  baby  on  the  breast 
will  be  found  empty  in  one  and  one-half  to  two  hours  after  the 
meal,  while  the  emptying  of  the  stomach  of  a  healthy  infant  on 
cow's  milk  will  usually  require  considerably  longer.  High  fat 
percentages  and  strong  dilutions  of  cow's  milk  greatly  lengthen 
this  time.  It  was  found  by  Cannon  that  solid  particles  of  food 
which  would  not  become  fluicf  or  semi-fluid  greatly  impeded  the 
emptying  of  the  stomach. 

Further  discussion  of  the  stomach  functions  will  be  con- 
sidered under  the  chapter  on  "  Vomiting." 

THE   INTESTINES 

Length  of  the  Intestines. — The  intestinal  tract  in  the  in- 
fant is  relatively  much  longer  than  in  the  adult.  In  the  new- 
born, the  length  of  the  intestines  is  six  times  that  of  the  body, 
while  in  the  adult  it  is  only  four  and  one-half  times  as  long. 

the  small  intestine 

The  small  intestine  is  divided  anatomically  into  three  parts: 
duodenum,  jejunum,  ileum. 

The  duodenum,  being  directly  continuous  with  the  pyloric 
end  of  the  stomach,  plays  an  important  role  in  the  process  of 
digestion  of  the  food.  It  is  here  that  the  secretions  from  the 
pancreas  and  liver  empty  into  the  bowel  and  become  mixed  with 
the  food.  The  liver  in  the  infant  is  relatively  much  larger  than 
in  the  adult.  The  secretion  of  bile  begins  soon  after  birth  and  is 
well  established  within  a  week  or  ten  days.  All  the  pancreatic 
secretions  are  present  in  the  new-bom,  although  in  small  quan- 
tities. The  most  important  of  the  digestive  ferments  found  in  the 
duodenum  are  the  following : 


ANATOMY  AND  PHYSIOLOGY  23 

Trypsin,  acting  best  in  an  alkaline  mediuna  and  converting 
proteid  into  peptone. 

Diastase,  converting  starch  into  sugar. 

Lipase,  splitting  fat  into  fatty  acids  and  glycerine. 

The  sudden  flow  of  bile,  according  to  some  authorities,  is  re- 
sponsible for  the  frequency  of  jaundice  in  the  new-born  infant 
(see  Chapter  XVI).     This,  however,  is  not  established. 

As  the  process  of  digestion  progresses  the  food  is  moved 
along  by  muscular  contraction  of  the  intestinal  walls,  the  digested 
product  being  absorbed  by  the  lacteals. 

The  small  intestine  joins  the  large  intestine  at  right  angles  at 
a  point  on  the  right  side  of  the  abdomen  at  the  ileocsecal  valve. 

The  Colon. — The  large  bowel,  or  colon,  begins  in  a  blind 
pouch,  called  the  caecum,  and  from  this  extends  a  rudimentary 
constricted  portion,  called  the  vermiform  appendix.  It  is  prob- 
able that  little  digestion  occurs  in  the  large  bowel,  although  there 
are  ferments  found,  capable  of  digestive  action. 

Functions  of  the  Colon. — The  chief  function  of  the  large 
bowel  is  that  of  absorption,  the  lower  portion,  or  rectum,  acting 
as  a  reservoir  for  the  fecal  matter  until  nature  or  convenience 
prompts  its  evacuation. 

The  colon  is  divided  into  three  portions,  according  to  posi- 
tion': ascending,  transverse,  descending. 

Sigmoid  Flexure. — The  lower  part  of  the  descending  colon 
in  the  infant  is  thrown  into  a  sharp  fold,  known  as  the  sigmoid 
flexure.  It  is  at  this  point  that  sometimes  in  artificially  fed  in- 
fants great  masses  of  fecal  matter  collect,  producing  persistent 
constipation. 

The  act  of  defecation  is  an  involuntary  act  produced  by  con- 
traction of  the  circular  muscle  fibres  of  the  rectum,  together  with 
the  abdominal  muscles  and  diaphragm,  accompanied  by  a  re- 
laxation of  the  sphincter.  Although  in  the  young  infant  the  act 
of  defecation  is  involuntary,  it  soon  becomes  more  or  less  volun- 
tary, and  the  infant  after  a  few  months  may  be  taught  to  empty 
the  bowel  at  regular  intervals. 


24         CARE  OF  INFANTS  AND  CHILDREN 

BACTERIA 

At  birth  the  digestive  tract  is  free  from  bacteria,  but  after  the 
food  has  been  ingested  it  swarms  with  micro-organisms  of  many 
varieties.  Most  of  these  under  ordinary  conditions  are  not  dis- 
ease-producing. Some  of  these  organisms,  the  colon  bacillus,  for 
example,  may  produce  serious  trouble  under  certain  conditions, 
and  particularly  if  it  gains  entrance  to  other  organs,  such  as  the 
urinary  tract. 

A  large  part  of  the  fecal  matter  is  made  up  of  bacteria  of 
various  forms. 

The  intestinal  flora  (bacterial  content)  of  the  bowel  is 
changed  radically  with  the  character  of  the  fopd. 

The  character  of  the  predominating  bacteria  in  children  fed 
on  breast  milk  is  radically  different  from  those  of  children  fed  on 
cow's  milk. 

The  Ductless  Glands 

Besides  the  glands  which  empty  their  secretions  through  ducts 
into  the  digestive  tract  and  other  cavities  of  the  body,  there  are 
a  number  of  others  whose  secretions  are  of  vital  importance  to 
the  growth  and  development  of  the  individual.  These  glands 
have  no  ducts  through  which  their  secretions  are  carried,  never- 
theless their  products  are  absorbed  and  carried  throughout. the 
body,  probably  by  both  the  lymphatics  and  the  blood  stream. 
The  most  important  of  these  glands  are :  the  spleen,  the  thymus, 
the  thyroid  and  parathyroids,  the  suprarenals,  the  pituitary,  the 
pineal,  the  testes,  and  the  ovaries. 

THE  SPLEEN 

The  spleen  is  the  largest  of  the  ductless  glands.  It  is  situated 
in  the  left  hypochondriac  region  behind  the  stomach,  and  extend- 
ing from  the  eighth  to  the  eleventh  ribs.  It  is  relatively  larger  in 
infants  than  in  adults,  and  is  prone  to  become  markedly  enlarged 
by  any  of  the  infectious  diseases. 

Enlargement  of  the   Spleen. — In   malaria  and   typhoid 


ANATOMY  AND  PHYSIOLOGY  25 

fever  the  spleen  is  frequently  so  largo  as  to  be  palpable  below  the 
margin  of  the  ribs. 

There  are  certain  conditions  of  the  blood  (splenic  anaemia, 
splenic  leukaemia)  in  which  the  spleen  is  enormously  enlarged. 
These  conditions  are  not  uncommon  in  children  and  usually  ter- 
minate fatally.  It  is  also  frequently  enlarged  in  rickets.  Careful 
microscoi)ic  examinations  of  the  blood  should  be  made  in  all 
cases  to  determine  the  exact  character  of  the  disease. 

THE  THYMUS 

The  thymus  is  a  temporary  organ,  situated  mostly  behind  the 
sternum,  in  front  of  the  lower  portion  of  the  trachea  and  large 
bronchi.  It  appears  at  the  second  month  of  intra-uterine  life. 
At  birth  it  measures  about  two  inches  in  length,  and  about  one- 
half  inch  in  thickness,  and  weighs  about  one  and  one-half 
drachms.  "  It  is  largest  when  the  child  is  two  or  three  years 
old  and  weighs  then  about  six  drachms.  From  that  time  on  it 
steadily  atrophies,  and  has  nearly  disappeared  by  the  fifteenth 
year."  In  infants  the  gland  has  a  particular  significance,  since 
sudden  enlargement  sometimes  occurs  resulting  in  pressure  upon 
the  nerves  and  trachea  or  bronchi,  producing  marked  attacks  of 
dyspnoea  and  sometimes  sudden  death.  Sudden  enlargement  of 
the  thymus  may  be  associated  with  general  lymphatic  enlarge- 
ment throughout  the  body.  This  condition  is  known  as  status 
lymphaticus. 

THE  THYROID  GLAND  , 

The  thyroid  gland  consists  of  two  lateral  lobes  connected  by  a 
narrow  portion  called  the  isthmus.  The  isthmus  usually  lies 
across  the  second,  third,  and  fourth  tracheal  rings. 

In  infancy  the  glands  are  relatively  larger  than  in  the  adult. 

Cretinism  and  Myxcedema. — The  secretions  of  this  gland 
are  absolutely  essential  both  to  the  physical  and  the  mental  de- 
velopment of  the  child.  The  congenital  absence  of  the  thyroid, 
or  insufficient  secretion  from  the  gland,  produces  the  condition 


26         CARE  OF  INFANTS  AND  CHILDREN 

known  as  cretinism  in  the  infant,  and  myxoedema  in  the  adult 
(page  174). 

Enlargement  of  the  gland  is  common  in  children;  and  esi>e- 
cially  in  girls  about  the  age  of  puberty,  producing  what  is 
clinically  known  as  goitre.  Unless  excessively  large  and  pro- 
ducing sym])toms  of  pressure,  simple  goitre  has  no  special 
clinical  significance  and  may  be  disregarded.  In  many  cases 
the  enlargement  gradually  disappears.  An  increased  secretion 
of  the  thyroid  gland  produces  a  chain  of  symptoms — muscular 
tremor,  rapid  heart,  and  sometimes  protrusion  of  the  eyes — 
known  as  hyperthyroidism  or  exophthalmic  goitre,  which  is, 
according  to  all  authorities,  extremely  rare  in  young  children. 

THE   PARATHYROIDS 

Imbedded  in  the  surface  of  each  lateral  lobe  of  the  thyroid 
body  are  two  little  masses,  each  one  about  one-quarter  inch  in 
diameter,  one  in  the  inner  and  one  in  the  outer  aspect.  They  are 
called  the  parathyroid  glands.  Their  absence  is  supposed  to  be  a 
causative  factor  of  tetany. 

THE   SUPRARENAL   GLANDS 

"  These  glands  are  situated  in  the  epigastric  region,  resting 
upon  the  top  and  the  inner  and  front  surfaces  of  the  kidneys,  to 
which  organs  they  are  attached  by  areolar  tissue." 

That  they  are  essential  to  life  has  been  demonstrated  by  the 
fact  that  death  quickly  ensues  when  they  are  entirely  removed, 
and  also  by  the  fact  that  their  degeneration  is  soon  followed  by 
disease.    Their  precise  function  is  still  unknown. 

The  secretion  of  these  glands  (adrenalin)  has  a  profound 
influence  on  blood-pressure  and  on  other  functions  of  the  body, 
such  as  general  muscular  activity  and  sugar  metabolism. 

PITUITARY  BODY 

This  is  a  small  gland  found  at  the  base  of  the  brain,  the  func- 
tion of  which  is  but  little  known.     Disease  of  this  gland  is  sup- 


ANATOMY  AND  PHYSIOLOGY  27 

posed  to  produce  an  affection  known  as  acromegaly,  in  which 
there  is  an  abnormal  growth  of  the  bones. 

PINEAL   GLAND 

Also  a  small  gland  found  at  the  base  of  the  brain,  the  func- 
tions of  which  are  little  known. 

Cases,  however,  are  on  record  in  which  tumors  of  this  gland 
were  associated  with  precocious  development  of  the  genital 
organs.  "  Nearly  all  of  the  cases  have  been  in  boys  between  four 
and  eight  years  of  age." 

OVARIES  AND  TESTES 

The  principal  functions  of  these  glands  are,  of  course,  the 
production  of  ova  and  spermatozoa. 

In  addition,  both  of  these  glands  have  an  internal  secretion 
which  is  essential  to  the  proper  development  and  maintenance  of 
various  bodily  functions. 

Tin-:  Braix  and  Nervous  System 
The  brain  is  contained  within  the  cranium,  which  cavity  it 
completely  fills.  There  is  no  special  difference  in  the  appear- 
ance of  the  brain  of  the  young  infant  and  that  of  the  adult.  Its 
functions,  however,  in  the  infant,  are  to  a  great  extent  unde- 
veloped. During  the  first  year  of  life,  the  brain  makes  an 
enormous  growth ;  in  fact,  the  growth  during  the  first  year 
exceeds  the  growth  during  the  entire  remaining  life  of  the  in- 
dividual. 

Circumference  of  the  Head  at  Different  Ages. — .During 
the  first  year  the  head  increases  a  little  over  four  inches  in 
circumference,  while  from  the  beginning  of  the  second  to  the 
fifth  year  there  is  an  increase  of  about  two  and  one-half  inches. 
From  the  fifth  to  the  twentieth  year  there  is  only  an  increase  of 
approximately  one  inch.  So  that  practically  the  entire  growth  of 
the  brain  occurs  during  the  first  six  years.  Such  an  enormous 
growth  during  the  first  year  is  only  possible  because  the  sutures 
and  fontanelles  remain  open. 


28         CARE  OF  INFANTS  AND  CHILDREN 

l^lvKLY  Closurk  of  FoNTANEi.LiiS  AND  SuTUKKS. — Occasion- 
ally the  sutures  and  fontanelles  close  during  the  first  few  months. 
In  such  cases  the  growth  of  the  head  remains  almost  at  a  stand- 
still (microcephalus).  Whether  the  closure  of  the  sutures  and 
fontanelles  in  these  cases  is  due  to  arrested  development  of  the 
brain,  or  whether  this  premature  closure  of  the  sutures  is  re- 
sponsible for  the  lack  of  brain  development,  there  is  still  some 
doubt.  It  is  probable,  however,  that  the  defect  rests  primarily 
with  the  brain  itself. 

.  Instability  of  the  Nervocs  System. — Associated  with  the 
rapid  growth  of  the  brain  during  the  first  year,  is  a  marked  in- 
stability of  the  nervous  system,  and  most  of  the  early  functions 
are  but  poorly  developed. 

The  child  is  more  helpless  than  the  young  of  any  of  the  other 
animals,  and  continues  to  be  absolutely  dependent  for  the  first 
two  years,  at  least. 

Instinct. — Instinct  is  but  poorly  developed  in  the  infant  as 
compared  with  other  animals. 

Development  of  the  Special  Senses 

Preyer,*  who  observed  the  development  of  the  dififerent  func- 
tions in  his  own  children,  beginning  after  birth,  has  made  the 
following  observations : 

Eye  Reflexes  and  the  Development  of  Vision. — The 
pupils  reacted  to  light  at  birth,  and  when  bright  light  was  brought 
close  to  the  eyes  of  the  sleeping  infant  the  eyelids  closed  tighter. 
When  the  baby  was  awake,  if  the  light  was  suddenly  brought 
close  to  the  face  it  closed  its  eyes.  Infants  distingiu'shed  light 
from  darkness  as  early  as  the  seventh  day  after  birth. 

At  two  months  the  eyes  followed  bright  objects  to  some  ex- 
tent. At  ten  months  the  child  gave  evidence  of  satisfaction  when 
the  lamps  were  lighted. 

During  the  first  few  days  the  eyes  remained  open  a  very  short 
time,  sometimes  one  remaininer  open  while  the  other  was  closed. 

*  Preyer,  Die  Seele  des  Kindes. 


ANATOMY  AND  PHYSIOLOGY  29 

When  the  hand  or  other  object  was  suddenly  brought  in  front 
of  the  eyes  there  was  no  evidence  of  reaction  by  way  of  wink- 
ing or  any  other  facial  movement  up  to  the  fifty-fifth  day. 

In  the  fourteenth  week  there  was  a  strong  reaction  shown  by 
the  eyes  to  rapidly  approaching  objects. 

There  began  to  be  coordinate  movements  of  the  eyes  as 
early  as  the  thirty-first  day  after  birth,  and  by  the  forty-sixth  day 
the  strabismus,  or  inco(")rdination,  had  largely  disappeared. 

At  ten  months  the  convergence  was  very  good. 

At  four  months  objects  were  followed  with  the  eyes. 

At  eighteen  weeks  the  child  reached  for  objects  held  in  front 
of  its  face. 

Hearing. — The  ears  probably  begin  to  functionate  soon  after 
birth,  or  as  soon  as  the  Eustachain  tubes  are  inflated  with  air. 

Sensation  to  pain  is  little  developed  at.  birth,  but  rapidly  de- 
velops during  the  first  month. 

Taste. — Taste  is  early  developed  and  during  the  first  month 
the  infant  distinguishes  between  sweet  and  sour  and  bitter. 

Smell. — The  sense  of  smell,  although  absent  at  birth,  is  early 
developed.  It  was  observed  by  Preyer  that  infants  as  early  as 
the  end  of  the  second  or  third  week  were  able  to  distinguish,  by 
the  sense  of  smell,  breast  milk  from  cow's  milk  or  soup. 

Touch,  Pain,  and  Temperature. — The  sensibility  to  touch, 
pain,  heat,  and  cold  is  present  at  birth  to  a  limited  extent,  but 
increases  rapidly  and  is  well  developed  within  the  first  few  weeks. 


CHAPTER  III 

CARE  OF  THE  NEW-BORN  INFANT 

As  soon  as  the  child  is  born  it  should  begin  to  breathe.  In 
order  to  do  this  freely  all  secretions  should  be  removed  from 
about  the  nose  and  mouth.  This  should  be  done  with  a  little 
sterile  absorbent  cotton  wet  in  normal  salt  or  boiic  acid  solution. 
Gauze  stretched  over  the  index-finger  should  not  be  used,  as  the 
mucous  membrane  of  the  mouth  is  injured  thereby.  From  this 
time  on  until  the  teeth  come  through  no  further  care  of  the  mouth 
is  necessary.  The  secretions  of  the  glands  keep  the  mouth  suffi- 
ciently clean  so  that  any  further  effort  is  liable  to  do  more  harm 
than  good. 

Tying  the  Cord. — For  the  tying  of  the  cord  a  stout  linen  or 
silk  ligature  should  be  provided,  which  has  been  thoroughly 
sterilized  by  boiling  for  fifteen  or  twenty  minutes. 

The  cord  is  usually  tied  immediately  after  birth,  but  under 
certain  circumstances  the  tying  is  somewhat  delayed. 

In  the  case  of  very  full-blooded  babies,  who  are  somewhat 
blue  when  born,  the  cord  is  sometimes  cut  and  the  infant  allowed 
to  bleed  slightly  before  the  ligature  is  tied.  In  most  cases,  and 
especially  where  the  infant  is  pale  and  weak,  the  pulsations  in  the 
cord  are  allowed  to  cease  before  the  cord  is  tied.  This  should 
never  be  done  except  under  the  supervision  of  a  physician. 

The  cord  is  usually  tied  at  a  point  one  to  two  inches  from  the 
umbilicus.  Two  ligatures  are  applied  and  the  cord  is  cut  be- 
tween. After  it  is  cut  the  end  of  the  stump  is  touched  with  a 
solution  of  iodine  (one-half  tincture  iodine,  one-half  alcohol). 

The  child  usually  begins  to  cry  directly  after  birth,  thus  ma- 
terially aiding  in  a  proper  inflation  of  the  lungs  with  air.  When 
the  child  does  not  cry  and  show  proper  symptoms  of  breathing, 
means  should  be  taken  to  aid  respiration. 

This  may  be  done  in  several  ways.  Dousing  the  face  and 
30 


CARE  OF  THE  NEW-BORN  INFANT  31 

chest  with  cold  water  is  a  favorite  means  of  stimulating  inspira- 
tory effort. 

The  lungs  may  be  inflated  by  directly  blowing  air  into  them, 
mouth  to  mouth,  or  through  a  tube  introduced  into  the  nose  or 
into  the  larynx  direct.  This  is  done  only  under  extreme  necessity, 
the  attending  possible  dangers  of  infection  to  the  infant  or  at- 
tendant being  apparent.  (A  pulmotor  may  be  used  to  ad- 
vantage.) 

Artificial  Respiratiox. — A  simple  method  of  producing 
artificial  respiration  is  the  following: 

Place  the  palm  of  one  hand  under  the  shoulders  and  back  of 
the  head,  the  palm  of  the  other  hand,  with  fingers  widely  spread, 
under  the  lower  part  of  the  pelvis,  posteriorly.  Forcibly  bend  the 
upper  portion  of  the  body  backward,  describing  such  a  curve  as 
shown  in  Figs.  10  and  1 1.  This  results  in  forcing  the  chest  wall 
upward  and  the  diaphragm  downward,  thus  tending  to  create  a 
vacuum  in  the  chest.  The  air  rushes  in  to  fill  this  vacuum,  thus 
inflating  the  lungs.  The  next  movement  is  exactly  the  reverse : 
bringing  the  child's  head  and  chest  forward  so  that  the  body  is 
bent  at  an  acute  angle.  This  results  in  diminishing  the  size  of  the 
chest  cavity  by  lowering  the  ribs  and  allowing  the  diaphragm  to 
ascend,  thereby  driving  a  part  of  the  air  out  of  the  lungs.  This 
movement  should  be  repeated  eighteen  or  twenty  times  a  minute, 
stopping  at  intervals  to  see  if  the  infant  will  take  up  the  work 
alone,  and  as  soon  as  it  is  demonstrated  that  it  is  breathing,  the 
artificial  means  should  be  discontinued.  The  infant,  however, 
should  be  carefully  watched  and  artificial  respiration  resumed 
whenever  necessary. 

Temper ATURE  of  Room  and  Loss  of  Heat. — It  must  be  re- 
membered that  new-born  infants  stand  exposure  to  cold  badly,  so 
that  if  it  is  necessary  to  use  cold  water  or  artificial  respiration, 
every  effort  must  be  made  to  protect  them  from  loss  of  heat.  The 
temperature  of  the  room  should  be  85°  or  90°  F.,  and  whenever 
possible  the  work  should  be  done  under  cover  of  a  warmed 
woollen  blanket. 


Fig.  10. 


Fig.  11. 

Fio.  10. — First  position  in  performinfj  artificial  respiration. 
Fig.  11. — Second  position  in  performing  artificial  respiration. 


CARE  OF  THE  NEW-BORN  INFANT  33 

Under  normal  conditions,  as  soon  as  the  cord  has  been  tied  the 
baby  is  wrapped  in  soft  warm  blankets  and  removed  to  an  ad- 
joining room  which  has  been  properly  heated  (70°  to  75*^  F.) 
and  placed  in  a  properly  prepared  basket  (Fig.  12),  an  ordi- 
nary clothes  basket  painted  white,  3  feet  long,  18  inches  deep, 
with  a  hair  mattress ;  a  woollen  blanket  may  extend  from  beneath 
the  mattress  over  the  sides  of  the  basket  for  greater  warmth. 


Fig.   12. — In  a  properly  prepared  basket. 

Bleeding  from  the  Cord. — The  cord  should  be  carefully 
watched  at  close  intervals  during  the  first  few  hours  for  bleed- 
ing, and  if  any  is  present  it  should  be  retied  on  the  proximal  side 
with  a  good  stout  ligature  of  linen  or  silk  which  has  been  prop- 
erly sterilized.  The  cord  should  be  wrapped  in  sterile  gauze  as 
soon  as  it  is  tied  and  the  same  degree  of  aseptic  precautions  taken 
in  guarding  it  against  infection  as  would  be  taken  in  an  open 
wound  in  the  abdomen,  since  the  opening  in  the  cord  communi- 
3 


34 


CARE  OF  INFANTS  AND  CHILDREN 


cates  for  a  time  directly  with  the  blood  stream,  the  collapsed  ves- 
sels running  directly  to  the  liver  and  vena  cava. 

Tin-:  SunsiiyuENT  Care  of  the  Cord 

Whatever  dressings  the  cord  receives,  the  important  points 
are:  to  keep  it  free  from  infection,  and  to  have  it  "  dry  up  " 
and  "  fall  off  "  as  soon  as  possible. 

After  cleansing  the  skin  around  the  navel,  the  cord  should 
be  enveloped  in  sterile  gauze  on  which  some  sterile  powder,  as 
starch  or  bismuth,  may  be  dusted.  It  is  questionable  whether 
the  powder  in  many  cases  serves  any  useful  purpose,  and  if  it  is 
not  absolutely  sterile  it  is,  of  course,  an  added  source  of  infec- 
tion. In  the  course  of  a  week  or  ten  days,  nature  forms  a  line 
of  demarcation  at  the  skin  margin,  and  the  dried  mummified 
cord  becomes  separated.  The  raw  surface  is  quickly  covered 
with  epithelium  and  becomes  inverted  into  the  umbilicus. 

Infection  of  the  Cord. — If  any  infection  occurs  the  skin 
around  the  umbilicus  at  once  becomes  red,  and  not  infrequently 
a  considerable  amount  of  pus  is  formed. 

Erysipelas  and  Tetanus. — The  navel  is  not  an  uncommon 
point  of  infection  with  erysipelas,  which  is,  of  course,  serious, 
if  not  always  fatal,  in  young  infants. 

Other  forms  of  infection,  such  as  tetanus  (lock-jaw),  not 
infrequently  have  their  origin  in  the  cord. 

Whenever  any  evidence  of  infection  of  the  cord  or  of  the 
skin  around  the  umbilicus  occurs,  the  physician's  attention 
should  be  called  at  once  to  the  condition,  the  old  stump  should 
be  removed  and  dressings  wet  with  boric  acid,  or  normal  salt 
solution,  applied. 

Granulations  in  the  Umbilicus. — Not  infrequently  a  very 
mild  infection  occurs  which  does  nothing  more  than  delay  the 
healing  of  the  umbilicus  after  the  separation  of  the  cord.  As 
a  result  of  this  mild  infection,  granulation  tissue  forms, 
not  infrequently  forming  a  polypoid  grozvth,  the  size  of  a  pea, 
with  a  small  pedicle  at  the  base.    Such  a  condition  will  keep  up 


CARE  OF  THE  NEW-BORN  INFANT       '  35 

a  continuous  discharge  from  the  navel  for  weeks  or  months.  It 
is  usually  necessary  for  the  physician  to  pick  up  the  growth 
with  forceps  and  tie  a  ligature  around  the  pedicle,  after  which  it 
promptly  dries  up.  The  only  subsequent  care  which  such  a  con- 
dition demands  is  the  maintenance  of  perfect  cleanliness  until 
healing  occurs.  A  little  sterile  cotton  wound  on  a  small  probe 
and  dipped  in  50  per  cent,  alcohol  will,  if  introduced  into  the 
folds  of  the  umbilicus,  keep  the  wound  clean. 

Umbilical  Hernia 

The  umbilical  opening  is  naturally  one  of  the  weak  points 
in  the  abdominal  wall.  Normally  the  opening  closes  as  soon  as 
the  cord  separates,  or  even  before.  In  a  rather  large  percentage 
of  cases,  for  some  reason  or  another,  the  umbilical  opening  does 
not  close  and  there  remains  an  opening  which  allows  abdominal 
contents,  a  knuckle  of  intestine,  or  portion  of  omentum,  to  pro- 
trude.   This  is  known  as  umbilical  hernia  (Fig.  13), 

Causes  of  Hernia. — This  condition  may  be  due  to  several 
causes.  Congenital  defect  in  the  abdominal  wall  is  probably  the 
most  common.  Infection  is  probably  also  a  common  cause.  Pro- 
longed crying  before  the  umbilical  opening  has  closed  is  undoubt- 
edly an  element  also  in  its  production.  A  snug,  not  tight,  ab- 
dominal binder  should  be  worn  until  the  umbilical  opening  has 
closed  ,-the  band  in  normal  cases  may  then  be  removed. 

Adhesive  Straps  for  Umbilical  Hernia. — When  hernia 
has  already  occurred  the  best  means  of  securing  an  obliteration 
of  the  hernial  opening  is  by  an  adhesive  strip,  two  inches  wide 
and  six  to  eight  inches  long,  applied  across  the  abdomen  tightly 
enough  to  secure  apposition  of  the  lateral  margins  (Fig.  14). 
This  strip  should  consist  of  oxide  of  zinc  plaster,  and  should  be 
left  in  place  as  long  as  possible,  or  until  it  begins  to  loosen  or 
becomes  soiled.  Usually  it  may  remain  a  week  or  ten  days  with- 
out being  changed. 

In  order  to  remove  it  and  dissolve  the  gum  from  the  skin, 
benzine  must  be  used,  having  constantly  in  mind  the  inflammable 


36 


CARE  OF  INFANTS  AND  CHILDREN 


and  explosive  character  of  this  fluid.  If  the  skin  is  much  ir- 
ritated it  may  be  necessary  to  apply  some  sterile  gauze  over  the 
irritated  places  and  to  make  the  adhesive  strip  longer,  thus  put- 


FlG.    13. — Umbilical  hernia. 


ting  less  tension  on  the  skin  in  any  one  place.  These  strips  will 
usually  have  to  be  worn  for  several  months  before  a  cure  can  be 
secured. 


1     -Application  of  adhesive  strap  for  cure  of  umbilical  hernia. 


The  old-time  button  or  coin  as  a  remedy  for  umbilical  hernia 
is  worse  than  nothing,  as  it  only  serves  to  crowd  the  abdominal 
muscles  further  apart. 


CARE  OP  THE  NEW-BORN  INFANT 


37 


Yarn  Trusses. — Inguinal  or  groin  hernias  in  infants  are  best 
treated  by  means  of  yarn  trusses  (Fig.  15).  A  skein  of  soft  wool 
yarn  of  the  proper  length  is  passed  around  the  body,  just  above 


Fig.   15. — Yarn  truss  for  the  treatment  of  inguinal  hernia. 

the  iliac  crests,  and  a  slip  noose  formed  in  front  so  that  the  knot 
comes  directly  over  the  hernial  ring.  The  free  end  is  then  passed 
between  the  thighs  and  along  the  line  of  the  gluteal  fold  and 


38  CARE  OF  INFANTS  AND  CHILDREN 

tied  or  pinned  behind  and  somewhat  to  one  side.  The  truss  may 
be  protected  from  the  discharges  by  means  of  a  piece  of  oiled 
muslin  rolled  around  the  yarn  where  it  passes  between  the  thighs. 
.  Several  skeins  should  always  be  on  hand  so  that  the  soiled  one 
may  be  removed  and  another  applied.  These  should  be  worn 
night  and  day  for  several  months,  at  least.  Before  the  truss  is 
applied  the  hernia  should  be  carefully  reduced.  This  can  usually 
be  done  with  the  child  in  a  recumbent  position,  the  pelvis  being 
somewhat  elevated  and  the  thighs  flexed  on  .the  abdomen.  If  the 
hernia  cannot  be  reduced  readily,  and  there  is  any  evidence  of 
strangulation,  as  evidenced  by  pain  or  shock,  a  physician  should 
be  summoned  at  once. 

Hydrocele  is  a  rather  common  affection  in  infants  in  which 
there  is  an  accumulation  of  fiuid  along  the  spermatic  cord  and  in 
the  scrotum.  This  is  often  mistaken  for  hernia.  A  hydrocele 
may  sometimes  be  reduced  by  pressure,  so  that  the  physician's 
attention  should  always  be  called  to  any  enlargement  in  the 
region  of  the  groin  so  that  a  differential  diagnosis  may  be  made. 

Care  of  the  Eyes 

The  eyes  should  be  washed  almost  immediately  after  birth 
with  a  solution  of  warm  boracic  acid,  and  if  the  mother  has  had 
any  previous  vaginal  discharge,  a  2  per  cent,  silver  nitrate  solu- 
tion, freshly  made,  should  be  dropped  into  both  eyes.  In  many 
States  this  is  now  compulsory  in  all  cases,  and,  since  it  is  a  recog- 
nized fact  that  80  per  cent,  of  all  cases  of  blindness  in  children 
are  produced  by  infections  contracted  at  the  time  of  birth,  it  is 
probable  that  in  the  near  future  this  law  will  be  enforced  in  all 
States.  It  should  be  remembered  that  silver  nitrate  stains  the 
linen  black,  and  should  therefore  be  carefully  used. 

In  all  cases  where  any  inflammation  of  the  eyes  becomes  ap- 
parent, as  evidenced  by  redness  or  gluing  of  the  eyelids  together 
by  secretion,  the  physician's  attention  should  be  called  to  the 
condition  at  once ;  a  smear  should  be  made  and  examined  under 
the  microscope,  and  if  the  condition  is  found  to  be  gonorrhoea 
the  most  heroic  measures  will  be  necessary  to  save  the  sight. 


CARE  OF  THE  NEW-BORN  INFANT  39 

For  mild  infections  a  solution  of  argyrol,  15  per  cent.,  dropped 
into  the  eyes  at  three-  or  four-hour  intervals,  will  frequently 
result  in  a  cessation  of  the  infection.  Solutions  of  argyrol  should 
be  made  fresh  every  few  days. 

If  there  is  any  discharge,  the  eyes  should  always  be  irrigated 
with  warm  boric  acid  solution  before  any  other  medicine  is 
introduced. 

Such  medication  as  silver  nitrate  should  never  be  used  in  the 
eyes  except  under  the  direction  of  a  physician.  (See  chapter  on 
Gonorrhoea'l  Ophthalmia,  page  166). 

Care  of  the  Skin 

Vernix  Caseosa. — The  skin  at  birth  is  usually  intensely  red 
in  color  and  covered  by  a  cheesy  substance  called  vernix  caseosa. 
The  quantity  of  this  substance,  however,  varies  greatly  in  differ- 
ent individuals.  It  is  tenacious  in  character  and  rather  difficult  of 
removal.  It  may  be  necessary,  in  order  to  remove  it  without 
using  undue  friction,  to  anoint  the  skin  with  oil  (preferably  olive 
oil)  and  then  roll  the  baby  up  in  warm  blankets  for  a  period  of  six 
to  twelve  hours.  If  the  baby  is  delicate,  or  the  vernix  caseosa  un- 
usually great  in  quantity,  the  bath  may  be  dispensed  with  for 
twenty-four  hours  or  longer. 

First  Hair. — The  body  of  the  Infant,  including  the  head,  is 
covered  with  a  growth  of  fine  hair.  Not  infrequently  the  color 
of  the  hair  on  the  head  is  quite  different  from  that  on  the  body. 
After  a  few  weeks  or  months  this  first  hair  falls  out,  to  be  re- 
placed, as  a  rule,  by  another,  usually  less  profuse,  crop,  many 
times  of  quite  a  different  color. 

bathing 

In  bathing  young  infants  several  important  points  must  be 
kept  constantly  in  mind. 

The  room  should  be  warm:  80°  to  85°  F.  During  cool 
weather,  when  the  regular  heating  plant  is  not  in  operation,  some 
other  heat  should  be  provided.  A  fireplace,  electric  heater,  gas 
heater,  or  oil  stove  may  be  utilized  to  advantage.    In  the  use  of 


40 


CARE  OF  INFANTS  AND  CHILDREN 


gas  stoves  one  must  be  extremely  careful,  as  not  infrequently 
sufficient  gas  escapes  to  be  extremely  injurious  to  the  infant. 
( >ne  must  also  remember  that  a  gas  heater  or  oil  stove  in  a  small 
bath-room  quickly  exhausts  the  oxygen.  Infants  should  there- 
fore not  be  kept  in  such  a  room  longer  than  necessary. 

Soft  and  Hard  Water. — ^The  water  for  the  bath  should  be, 
if  jx)ssible,  rain  water ;  that  is,  what  is  generally  known  as  "  soft 
water."  If  "  hard  water  "  is  used  some  borax  may  be  added  to 
advantage  (one  teaspoon  to  one  gallon). 

Temperaturk  of  Water;  Soar. — The  water  should  have  a 
temperature  of  98°  to  100°  F.  The  soap  should  be  of  the  best 
quality  (castile),  as  cheap  soap  frequently  contains  free  alkali 
and  is  extremely  irritating  to  the  delicate  skin  of  the  infant. 

Wash  Cloths. — Wash  cloths  of  soft  material  should  be 
used,  and  after  they  have  been  used  once  they  should  be  dis- 
carded, until  they  have  been  washed  and  boiled.  Soiled  wash 
cloths  are  frequent  sources  of  infection.  It  is  well,  therefore,  to 
have  two  sets  of  wash  cloths  of  different  materials. 

Friction  of  the  Skin. — Little  friction  should  be  used  in 
washing  the  skin,  and  if  the  vernix  caseosa  is  not  readily  re- 
moved at  the  first  bath  it  may  remain  until  the  second  or  third. 
Undue  friction  during  the  bath  associated  with  an  impure  soap  is 
frequently  followed  by  a  dififuse  rash  in  which  the  skin  is  in- 
tensely red  and  covered  with  tiny  pustules.  This  condition  may 
be  readily  relieved  by  discontinuing  the  bath  for  a  few  days  and 
keeping  the  skin  powdered  with  stearate  of  zinc. 

During  the  first  week  or  ten  days,  or  before  the  cord  comes 
off,  only  sponge  baths  should  be  given,  which  should  not  last 
more  than  five  or  ten  minutes.  If  the  temperature  of  the  room  is 
below  80°  F.  the  bath  should  be  given  under  a  blanket.  Sponges 
should  not  be  used  because  they  cannot  be  kept  clean. 

In  bathing  an  infant  special  attention  should  be  directed  to- 
ward the  folds  of  the  skin,  particularly  about  the  genitals,  under 
the  arms,  and  in  and  back  of  the  ears.  After  carefully  removing 
all  secretions,  the  skin  should  be  powdered  with  talcum  powder, 


CARE  OF  THE  NEW-BORN  INFANT 


41 


or  better,  stearate  of  zinc,  except  about  the  genitals  in  female 
children. 

Excoriation  of  the  Skin. — If  the  skin  is  already  excoriated 
about  the  genitals  some  bland  ointment,  such  as  oxide  of  zinc, 
should  be  used  to  protect  the  skin  from  the  irritating  action  of 


Fig.  16. — Shower  bath 


the  urine  and  stool.  In  these  cases  liquid  albolene  may  be  used 
to  sponge  the  skin  instead  of  water. 

The  diapers  should  be  changed  always  as  soon  as  they  are 
soiled,  and  the  parts  washed  with  warm  water  and  the  ointment  or 
powder  reapplied. 

Bathing  the  Genitals. — In  bathing  girl  babies  about  the 
genitals  the  following  precautions  should  be  observed,  in  order 


42 


CARE  OF  INFANTS  AND  CHILDREN 


to  prevent  infections  of  the  urinary  tract  by  fecal  matter:  After 
removing  a  soiled  diaper  the  skin  should  first  be  cleansed  in  the 
region  around  the  genitals.  Separate  pledgets  of  cotton  should 
then  be  used,  sponging  always  backward  and  away  from  the 
urethra. 

After  bathing,  the  skin  should  be  dried  with  a  soft  towel  by 
sponging,  not  by  rubbing. 


Fig.   17.— Folding  bath-tub. 

After  the  first  few  weeks  the  sponge  bath  may  be  dispensed 
with  and  the  baby  put  in  the  tub,  or,  better  still,  given  a  shower 
(Fig.  i6). 

A  great  variety  of  bath-tubs  are  on  the  market.  The  ac- 
companying Fig.  17  shows  a  convenient  form  of  folding  tub 
which,  with  the  folding  table  (Fig.  18),  may  be  put  out  of  the 
way  after  the  bath  is  over. 

Shower  Bath. — In  institutions  where  many  infants  are  to 


CARE  OF  THE  NEW-BORN  INFANT 


43 


be  bathed  one  after  another,  bath-tubs  should  never  be  used. 
The  baby  should  be  placed  on  a  porcelain  slab,  covered  with,  a 
folded  bath  towel.  This  towel  should  be  changed  for  each  in- 
fant and  the  slab  well  showered  off.  An  apparatus  such  as 
shown  in  Fig.  19  is  now  in  general  use  in  hospitals.  The  water 
in  the  tank  is  first  mixed  to  the  proper  temperature  by  the;  at- 
tached thermometer  (95°  to  100°  F.).  The  bath  should  be  of 
short  duration  and  the  infant,  after  careful  drying,  should  be 
wrapped  in  warm 
blankets. 

Cold  Baths. — Cold 
baths  should  never  be 
given  to  young  infants, 
as  they  lose  heat  rapidly 
and  usually  do  not  react. 
Sudden  chilling  of  the 
skin  will  usually  be  fol- 
lowed in  infants  by  catar- 
rhal affections  of  the  re- 
spiratory and  digestive 
tracts.  After  a  few 
months  the  temperature  F'^-  is.-Foiding  table. 

of  the  bath  may  be  somewhat  reduced,  and  after  one  year  the 
chest  and  neck  as  well  as  the  face  may  be  sponged  with  cool  water. 

It  should  be  borne  in  mind  that  babies  can  get  along  without 
baths  for  a  limited  period  when  the  condition  demands  it.  Olive 
oil  rubs  may  be  substituted. 

Bathing  of  Older  Children 

In  older  children  the  daily  "  tub  "  is  a  fine  way  to  begin  the 
day.  A  short  dip  in  cool  water  and  a  good  vigorous  rub  put 
children  in  a  good  frame  of  mind,  which  they  are  apt  to  carry 
throughout  the  day.  In  children  who  are  prone  to  take  cold 
easily,  daily  sponging  of  the  chest  and  throat  with  cold  water 
will  often  do  much  to  lessen  this  tendency. 


44 


CARE  OF  INFANTS  AND  CHILDREN 


Cake  of  the  Genital  Organs 

There  is  a  great  diversity  of  opinion  among  physicians  as  to 
the  proper  care  of  the  genital  organs  in  boys. 

According  to  the  Jewish  Ritual,  which  has  been  in  vogue  for 
three  thousand  years,  all  male  infants  are  circumcised.  This  was 
primarily  a  sanitary  precaution,  which  became,  like  all  their  laws, 
a  ])art  of  their  religious  duties. 


1 


Fig.    19. — Shower  bath  for  infants. 


The  water  is  first  mixed  in  the  tank  to  the  proper 
temperature. 


An  adherent  foreskin  is  normal  in  all  male  infants.  There  is, 
however,  a  great  difference  in  the  character  of  the  opening  and 
in  the  length  of  the  foreskin  in  individual  cases. 

A  large  percentage  of  all  cases,  if  left  alone,  will  light  them- 
selves in  a  few  months.  There  are,  however,  cases  in  which  the 
foreskin  is  so  tightly  adherent  around  the  urinary  meatus  that  it 
will  never  become  normal,  so  that  it  can  be  pushed  back.    There 


CARE  OF  THE  NEW-BORN  INFANT  45 

are  other  cases  in  which  the  foreskin  is  so  long  that,  even  if  it  can 
be  pushed  back,  it  is  almost  impossible  to  keep  the  organ  free 
from  secretions,  which  quickly  become  foul  and  irritating. 

The  best  opinion,  therefore,  now,  is  that  the  foreskin  should 
be  left  alone  for  the  first  few  months,  in  order  to  see  if  nature 
will  take  care  of  the  condition  herself.  If  any  local  irritation 
arises  in  the  meanwhile,  the  physician  must  decide  how  best  to 
meet  it.  It  may  be  necessary  to  stretch  the  foreskin  and  push 
it  back,  or  it  may  be  better  in  certain  cases  to  perform  circum- 
cision. There  is  undoubtedly  far  too  much  interference,  on  the 
part  of  both  medical  men  and  nurses,  with  the  genital  organs  of 
infants. 

After  the  foreskin  can  be  readily  pushed  back,  this  should  be 
done  two  or  three  times  weekly  during  the  bath  and  the  organ 
cleansed,  the  same  as  the  rest  of  the  body.  No  special  attention 
should  be  drawn  to  the  genital  organs,  and  close  watch  should 
be  directed  to  the  possible  formation  of  habits  (masturbation), 
which  can  more  easily  be  prevented  than  cured. 

For  female  infants  it  is  usually  sufficient  to  keep  the  genital 
organs  clean.  All  secretions  should  be  carefully  removed  from 
the  folds  with  warm  water  and  sterile  pledgets  of  cotton.  Female 
infants  are  particularly  susceptible  to  infections  of  the  genito- 
urinary tract,  so  that  the  utmost  care  must  be  taken  against  pos- 
sible contamination. 

Dusting  powders,  such  as  talcum,  boric  acid,  etc.,  should  never 
be  used  in  or  about  the  vagina  in  infants.  They  simply  serve  as  a 
foreign  body  and  produce  irritation. 

If  some  irritation  is  already  present,  a  simple  ointment,  such 
as  vaseline,  may  be  used  to  protect  the  mucous  membrane  from 
the  action  of  the  urine  until  the  surface  becomes  normal. 


CHAPTER  IV 
THE  NURSERY  AND  ITS  EQUIPMENT 

The  room  chosen  for  the  nursery  should  be  of  good  size  and 
have  at  least  two  windows,  which  should  face  in  different  direc- 
tions. The  room  should  be  so  located  that  it  will  have  the  direct 
sunlight  for  a  part  of  each  day,  at  least.  A  south  and  east  fac- 
ing room  is  generally  to  be  preferred,  since  during  the  winter 
months  the  sun  shines  in  these  windows  the  greater  part  of  the 
day,  and  during  the  mid-summer  months  the  intensely  hot  after- 
noon sun  is  to  a  great  extent  avoided. 

Flies  should  be  absolutely  excluded,  as  they  are  frequent 
sources  of  infection,  as  well  as  discomfort. 

The  windows  should  be  provided  with  screens,  dark  shades, 
and  awnings  for  summer.  The  old-fashioned  green  shutters 
are  a  valuable  adjunct  to  a  nursery,  as  they  may  be  closed  and  so 
arranged  as  to  shut  out  most  of  the  light  and  still  admit  the  air. 
Hangings  should  be  as  far  as  possible  dispensed  with  and  only 
the  simplest  wash  curtains  permitted. 

The  Floors. — ^The  floors  should  be  of  hard  wood  and  par- 
tially covered  with  small  rugs  which  can  be  readily  washed.  A 
vacuum  cleaner  is  the  ideal  way  of  cleaning  the  floors  and  walls, 
and  if  sweeping  is  necessary  the  baby  should  always  be  removed 
from  the  room,  and  for  at  least  an  hour  afterwards.  Carpet 
sweepers  are  preferable  to  sweeping  with  a  broom,  since  by  the 
latter  process  the  dust  simply  changes  location. 

The  Walls. — The  walls  of  the  nursery  should  be  of  plaster 
which  has  been  painted  some  restful  color  and  which  may  be 
wiped  down  with  a  damp  cloth  without  injury.  Hangings  and 
pictures  with  frames  should  be  dispensed  with  as  far  as  possible 
and  in  place  a  fresco  of  appropriate  figures  may  be  substituted. 

Ventil.\tion. — The  air  in  the  nursery  should  be  fresh.  It  is, 
46 


THE  NURSERY  AND  ITS  EQUIPMENT  47 

-therefore,  necessary  to  have  a  constant  change  of  air  from  with- 
out. The  old  rule  requiring  three  thousand  cuhic  feet  of  air  per 
hour  per  person  is  still  a  safe  one  to  follow,  although  recent  in- 
vestigations have  apparently  to  some  extent  modified  this  law. 

During  the  summer  months,  when  the  weather  is  warm,  it  is 
not  difficult  to  live  up  to  this  requirement,  but  in  winter  it  be- 
comes a  problem,  when  the  temperature  of  the  room  must  be 
maintained. 

Opening  a  window  slightly  both  at  top  and  bottom  creates  a 
rotary  motion  of  the  air,  thereby  promoting  good  ventilation. 

There  are  various  kinds  of  window  ventilators  which  are 
more  or  less  efficient. 

At  least  once  daily  the  windows  should  be  thrown  wide  open 
and  the  wind  allowed  to  blow  freely  through  the  room.  This, 
however,  is  not  in  itself  sufficient,  and  some  change  of  air,  how- 
ever slight,  should  constantly  be  enforced. 

Not  more  than  one  person  should  be  in  a  small  room  at  one 
time  with  a  baby,  and  when  it  is  asleep  it  should  be  alone.  The 
nurse  should  sleep  in  an  adjoining  room  with  the  door  open,  so 
that  any  noise,  coughing,  vomiting,  crying,  etc.,  may  be  heard. 

A  bath-room  adjoining  the  nursery  is  not  a  necessity,  but  a 
great  convenience. 

Temperature. — The  temperature  of  the  nursery  for  the  first 
few  months  should  be  about  70°  F.  during  the  day,  and  at  night 
slightly  lower.  The  only  time  when  the  temperature  should  l)e 
above  this  point  is  during  the  bath,  and  if  there  is  an  adjoining 
bath-room  where  the  temperature  may  be  more  easily  maintained 
the  nursery  need  never  be  raised  above  70°  F.  After  a  few 
months  the  temperature  at  night  may  be  as  low  as  60°  F.,  and 
after  the  first  year  as  low  as  40°  F. 

Young  infants  should  never  be  put  to  sleep  in  a  zero  tem- 
perature. Because  all  infants  so  exposed  do  not  have  pneumonia 
is  not  an  argument  in  its  favor. 

The  essential  thing  is  that  the  air  be  fresh.  Tt  is  not  neces- 
•sary  that  the  air  should  be  cold  in  order  to  be  fresh,  and  all  cold 


48  CARE  OF  INFANTS  AND  CHILDREN 

air  is  not  by  any  means  fresh.  For  example,  it  is  a  common  oc- 
currence to  see  a  whole  family,  father,  mother,  and  several  chil- 
dren, sleeping  on  a  porch  with  the  windows  all  closed.  The  air 
may  be  cold,  but  is  anything  but  fresh. 

Electric  Fans. — During  hot  weather  an  electric  fan  is  most 
useful  in  a  nursery.  No  matter  how  hot,  if  the  air  can  be  kept 
in  motion,  an  infant  with  a  scant  enough  supply  of  clothing  can 
usually  be  kept  comfortable. 

Heating. — The  heating  of  the  nursery  is  a  matter  of  great 
importance.  In  the  modern  home  in  the  city  and  larger  towns  a 
central  heating  system  is  generally  in  use.  This  may  be  hot 
water,  steam,  or  hot  air.  Perhaps  the  one  which  can  be  most 
uniformly  regulated  is  hot  water.  In  addition  to  the  general 
heating  plant,  an  open  fireplace  or  wood  stove  is  invaluable. 
There  are  many  days  during  the  spring  and  fall,  after  the  fur- 
nace fire  has  been  discontinued,  when  some  heat  in  the  nursery 
is  absolutely  necessary.  An  open  fireplace  is  also  a  valuable  aid 
to  ventilation. 

Moisture. — A  certain  amount  of  moisture  in  the  air  is  abso- 
lutely essential  to  health.  Open  dishes  with  water  should  be 
placed  on  the  radiators,  or  cans  which  are  adjusted  to  and  behind 
the  radiators.  The  amount  of  humidity  should  be  not  less  than 
50  or  55  per  cent. 

Lighting. — 'The  nursery  should  be  preferably  lighted  by 
electricity,  proper  shades  being  provided.  Next  to  this  a  kero- 
sene lamp  is  to  be  preferred ;  it  should,  however,  never  be  al- 
lowed to  burn  during  the  night,  as  it  creates  a  smell,  and,  like 
any  other  flame,  uses  up  the  oxygen.  A  gas  jet  should  never  be 
allowed  in  a  sleeping  room.  It  is  dangerous,  and,  even  if  no  one 
"  blows  it  out,"  there  is  usually  enough  gas  escapes,  even  when 
turned  ofif",  to  contaminate  the  air  and  make  it  a  menace  to 
health. 

If  some  light  must  burn  at  night  in  the  nursery,  a  small  wax 
candle  will  show  sufficient  light  and  use  up  a  minimum  of 
oxygen. 


THE  NURSERY  AND  ITS  EQUIPMENT  49 

Beds. — By  far  the  best  bed  for  a  new-born  baby  is  an  ordi- 
nary clothes  basket  which  has  been  painted  with  white  enamel. 
If  any  draping  is  used  it  should  be  of  simple  wash  material.  The 
basket  should  be  fitted  with  a  properly  fitting  mattress  stuffed 
with  fine  excelsior,  or  hay,  or,  if  something  more  expensive  is 
desired,  it  may  consist  of  hair  or  moss.  The  mattress  should  be 
protected  by  a  waterproof  sheet,  and  this  in  turn  covered  by  a 
cotton  pad ;  otherwise  the  discharges  will  soon  render  it  foul  and 
therefore  useless.  Feather  pillows  should  not  be  used  as  a  mat- 
tress ;  they  are  hot  and  unsanitary,  particularly  in  warm  weather. 

The  advantages  of  the  basket  during  the  first  months  are  that 
it  is  cheap,  readily  moved  about,  and  the  high  sides  offer  a  pro- 
tection from  the  cold  as  well  as  from  possible  injury  (by  being 
sat  upon,  for  example).  The  basket  should  be  placed  on  a  low 
table  or  on  two  chairs  (see  p.  ^7,). 

At  the  age  of  six  months  to  a  year  the  baby  may  graduate  and 
in  the  future  occupy  a  real  bed  instead  of  the  basket. 

The  crib  should  be  of  iron  painted  with  white  enamel.  The 
sides  should  be  capable  of  being  lowered  (Fig.  20),  and  for  hos- 
pital use  a  bed  in  which  the  springs  and  mattress  can  be  raised 
within  the  frame  to  the  desired  height.  This  is  a  great  conveni- 
ence in  case  of  illness,  as  the  constant  stooping  over  a  low  bed  is 
extremely  fatiguing  to  the  attendants.  The  mattress  of  the  crib 
may  be  of  the  same  materials  as  that  of  the  basket  and  should  be 
covered  with  waterproof  material  and  a  cotton  pad. 

In  addition  to  the  bed,  or  basket,  a  nursery  should  contain  the 
following  articles  of  furniture  and  other  utensils : 

Folding  Table. — A  folding  or  ordinary  kitchen  table  upon 
which  the  baby  may  be  dressed,  undressed  and  changed  (see  p. 
43).  The  top  should  be  covered  with  oil-cloth,  which  should  be 
washed  off  daily  with  a  damp  cloth. 

A  bed  screen,  to  be  covered  with  simple  wash  material. 

Dressing  Table. — A  dressing  table  with  a  glass  or  porcelain 
top  and  a  shelf  below,  also  of  glass  or  porcelain.  A  railing  one 
4 


50 


CARE  OF  INFANTS  AND  CHILDREN 


inch  high  should  surround  the  top  and  shelf,  to  prevent  articles 
from  falling  off.  The  legs  of  the  table  should  be  provided  with 
large  castors  so  that  it  may  be  readily  moved  about  the  room.    It 


Fig.   20.— The  Hornsby  bed. 


should  be  low  enough  to  be  reached  by  the  nurse  without  get- 
tine  up.  The  table  should  be  equipped  with  the  following 
articles : 


THE  NURSERY  AND  ITS  EQUIPMENT  51 

1.  One  bath  thermometer.  10.  Castile  soap  (best  quality). 

2.  Clinical  thermometer.  il.  Blunt  bandage  scissors. 

3.  Talcum  powder  (unscented).  12.  Safety  pins   (assorted  sizes). 

4.  Stearate  of  zinc  powder.  13.  Needles  and  white  thread. 

5.  Tube  of  yellow  vaseline.    (The  14.  Soft  wash  cloths  and  towels, 
jar  vaseline  is  unsanitary.)  15.  Soft  baby  hair-brush. 

6.  Boric  acid  crystals.  16.  Absorbent  cotton    (sterile). 

7.  Box  zinc  oxide  ointment.  17.  Tooth-picks,    to    wrap    cotton 

8.  Bottle  of  alcohol.  on,  as  swabs  (to  be  discarded 

9.  Bottle   of    sweet   oil    or   olive  and  burned  after  using), 
oil. 

In  a  wardrobe  close  by  should  be  a  stock  of  proper  clothing, 
and  particularly  a  large  supply  of  clean  diapers  and  towels. 

Beside  the  table  should  stand  a  low  chair,  without  arms,  for 
the  nurse. 

An  air-tight  receptacle  for  the  soiled  diapers  should  stand 
preferably  in  the  adjoining  bath-room.  The  diapers  may  then  be 
taken  at  any  time  to  the  laundry,  but  if  it  is  necessary  to  preserve 
them  for  the  physician's  inspection,  they  may  be  kept  without 
rendering  the  air  of  the  nursery  unwholesome.  Diapers  should 
be  washed  with  white  soap,  rinsed  through  two  waters  and  boiled 
before  being  hung  up  to  dry. 

Scales. — The  nursery  should  also  contain  scales  for  the 
regular  weighing  of  the  baby  (page  67). 

After  the  baby  is  one  year  old  a  chair  and  table  of  the  proper 
relative  height  may  be  provided. 


CHAPTER  V 
TIME  TO  BE  SPENT  OUT  OF  DOORS 

During  the  summer  months,  when  the  weather  is  warm,  even 
very  young  infants  should  be  out  of  doors  as  much  as  possible. 
They  can,  however,  usually  get  sufficient  sun  and  air  on  their  own 
porches,  or  in  their  own  yards.  Infants  should  be  kept  as  quiet 
as  possible  and  should  never  be  pushed  about  the  street  in  a 
carriage  or  taken  in  an  automobile.  Such  procedures  expose 
them  to  dust  and  excitement,  from  which  they  will  certainly  show 
the  efifects  in  catarrhal  inflammation  of  the  upper  air  passages 
and  in  restlessness  and  inability  to  sleep. 

During  the  extremely  hot  weather  the  rooms  on  the  shady 
side  of  the  house  will  frequently  be  found  cooler  than  out  of 
doors.  Screened  beds,  which  can  be  placed  on  the  porch  or 
extended  from  the  window  (Figs.  21  and  22),  may  be  purchased 
or  readily  made,  by  a  simple  frame  covered  with  mosquito 
netting. 

In  crowded  parts  of  the  city,  particularly  in  the  tenements, 
children  should  be  taken  into  the  open  spaces  in  the  parks  as 
much  as  possible  during  the  hot  weather. 

During  the  winter  months  in  the  northern  climate  it  is  fre- 
quently a  difficult  problem  to  decide  just  how  much  time  young 
infants  should  spend  out  of  doors. 

Vigorous  infants  who  are  born  at  the  beginning  of  winter 
should,  during  the  first  two  or  three  months,  be  taken  out  only 
when  the  temperature  is  above  50°  F.,  and  then  not  when  the 
wind  is  blowing  strongly  and  the  air  is  full  of  dust. 

After  five  months  the  baby  may  sleep  out  of  doors  when  the 
sun  is  shining  and  the  temperature  is  not  much  below  the  freez- 
ing point  (25°  to  30°  F.).  If  infants  are  gradually  accustomed 
to  sleeping  in  progressively  lower  temperatures  no  harm  results, 
52 


TIME  TO  BE  OUT  OF  DOORS 


53 


Fig.  22. — Screened  bed  extending  from  the  window. 


54 


CARE  OF  INFANTS  AND  CHILDREN 


up  to  a  certain  point.  Children  who  are  suddenly  taken  from  a 
warm  room  and  put  out  to  sleep  at  zero  temperature  are  liable 
to  develop  catarrhal  inflammation  of  the  respiratory  tract. 

The  important  thing"  to  remember  in  this  connection  is  that 
young-  children  do  not  tolerate  well  extremes,  either  of  heat  or 
cold. 

It  must  be  here  again  emphasized  that  it  is  not  necessary  that 
air  shall  be  cold  in  order  to  be  fresh. 


CHAPTER  VI 
SLEEP 

Infants  during  the  first  year  should  sl6ep  about  three- 
quarters  of  the  time. 

During  the  second  year  they  should  sleep  two-thirds  of  the 
time,  or  about  sixteen  hours  out  of  twenty-four,  and  up  to  the 
sixth  year  children  should  sleep  twelve  to  fourteen  hours,  that  is, 
twelve  hours  at  night  and  two  hours  during  the  day. 

Effects  of  Sleep. — It  is  during  sleep  that  the  process  of  re- 
pair is  probably  most  active.  The  remarkably  rapid  growth  of 
the  brain  during  the  first  years,  together  with  the  numberless  im- 
pressions made  daily  upon  the  brain  cells,  makes  a  proper  amount 
of  sleep,  under  the  most  favorable  conditions,  an  absolute  neces- 
sity— if  we  are  to  have,  later  in  life,  a  normal  individual. 

Respiration  During  Sleep. — The  sleep  of  young  infants 
and  children  should  be  practically  noiseless.  The  respirations  are 
deeper  and  slower  than  during  waking  hours,  although  in  younrj 
infants  the  rhythm  is  many  times  very  irregular,  and,  as  de- 
scribed before  under  '*  Respiration,"  is  largely  diaphragmatic  in 
character. 

Nose-  and  Moutii-Breatiiing. — The  infant  should  breathe 
through  the  nose,  with  the  mouth  closed.  Mouth-breathing  is 
not  at  all  uncommon  even  in  new-born  infants,  and  it  indicates 
the  presence  of  a  large  postpharyngeal  tonsil  (adenoid). 

Temperature  of  Room. — The  air  during  sleep,  as  well  as 
during  the  waking  hours,  should  be  fresh,  but  during  the  first 
few  months  the  temperature'  should  not  go  below  50°  F.  An 
infant  should  never  sleep  in  the  same  bed  with  the  mother  or 
nurse,  but  should  have  a  bed  of  its  own.  It  is  not  uncommon  that 
infants  are  accidentally  smothered  by  sleeping  with  the  mother. 

55 


56  CARE  OF  INFANTS  AND  CHILDREN 

An  infant  who  sleeps  with  the  mother  is  hable  to  nurse  at  inter- 
vals throughout  the  night — much  to  the  detriment  of  both  mother 
and  infant. 

Infants  should  be  nursed  and  then  put  down,  and  not  taken 
up  unless  to  change,  for  at  least  one  hour  after  feeding. 

Rocking  and  Walking  the  Bai-.v. — Infants  should  not  be 
rocked  or  walked  to  sleep,  since  the  baby  will  usually  promptly 
wake  again  as  soon  as  the  movement  ceases  and  the  process  will 
have  to  be  renewed,  with  a  consequent  loss  of  much  energy  and 
sleep  on  the  part  of  the  mother  and  the  household  generally. 

If  a  baby  is  well  and  comfortable,  "not  soiled,"  and  has  a 
sufficient  amount  of  food  (breast  milk)  at  proper  intervals,  it 
will  sleep  three-quarters  of  the  time  during  the  first  months. 

Restlessness  During  Sleep. — Some  of  the  common  causes 
of  restless  and  irregular  sleep  are  :  overfeeding ;  too  much  cloth- 
ing ;  sleeping  in  a  hot,  badly  ventilated  room  ;  having  been  spoiled 
by  rocking,  walking,  etc. ;  discomfort  from  soiled  diapers ; 
hunger;  inability  to  breathe  properly  through  the  nose,  due  to 
acute  coryza  or  adenoids  ;  rickets,  or  some  other  form  of  malnu- 
trition;  constipation  (hard  masses  of  fecal  matter  in  the 
rectum)  ;   infections  generally — particularly  of  urinary  tract. 

A  baby  should  sleep  on  a  mattress,  made  preferably  of  hair. 

Position  During  Sleep. — There  should  be  no  pillow,  but 
the  mattress  should  have  a  gradual  incline,  the  head  being  a 
couple  of  inches  higher  than  the  lower  part  of  the  body.  It  will 
be  found  that  if  the  upper  part  of  the  body  is  slightly  higher 
than  the  lower,  the  baby  will  not  regurgitate  as  much  food  as  if, 
as  is  generally  the  case,  its  heels  are  higher  than  its  head. 

The  position  of  a  child  should  be  changed  at  intervals.  It 
may  be  placed,  directly  after  feeding,  on  the  right  side,  and  later 
on  the  left. 

Soiled  Diapers. — When  the  diapers  are  soiled  it  should  be 
taken  up  and  changed  at  once.  An  infant  who  is  allowed  to  lie 
all  night  in  a  diaper  soaked  with  urine,  or  in  addition  fecal  mat- 
ter, will  usually  sleep  badly  and  the  skin  under  the  diaper  will 


SLEEP  57 

usually  be  irritated,  with  an  added  possibility  of  an  infection  of 
the  urinary  tract. 

Children  during  sleep  should  be  as  undisturbed  as  possible. 
They  should  have  their  own  room  and  no  light  should  be  allowed. 
Every  one  in  the  household,  however,  should  not  be  made  to 
whisper  in  order  to  secure  absolute  quiet  for  the  baby.  If  infants 
are  properly  trained  they  will  usually  sleep  soundly  throughout 
the  usual  sounds  which  occur  in  the  routine  of  household  duties. 
Loud,  sudden  noises,  however,  should  be  avoided. 

Sleep  After  the  Third  Year. — Children  after  the  third 
year  frequently  sleep  too  much  during  the  day  and  not  enough 
at  night.  Children  should  be  put  to  bed  regularly  at  the  same 
hour,  six  or  seven  o'clock,  and  during  the  day,  with  the  excep- 
tion of  the  nap  of  a  couple  of  hours,  should  be  out  of  doors  in 
good  weather,  even  in  winter,  running  and  playing  about.  Chil- 
dren who  are  physically  tired  will  eat  better,  digest  better,  de- 
velop better,  and  sleep  better  than  those  who  are  pushed  about  in 
a  perambulator  or  taken  about  the  country  in  a  limousine. 

Mid-day  Nap. — The  habit  of  taking  a  nap  in  the  middle  of 
the  day  (directly  after  lunch  is  the  best  time)  should  be  enforced 
as  long  as  possible.  Children  who  are  active  throughout  the 
day,  either  at  school  or  at  play,  should  relax  for  at  least  one 
hour,  even  if  they  do  not  sleep.  If  overworked  mothers  could 
be  persuaded  to  adopt  a  rule  of  resting  for  a  half -hour  or  so  in 
the  afternoon,  the  responsibilities  of  rearing  a  family  would  as- 
sume a  rosier  hue  than  they  many  times  do. 


CHAPTER  VII 
TEMPERATURE 

The  normal  temperature  of  an  infant,  as  of  an  adult,  is 
987^°  F.  There  are  slight  variations  from  this  temperature 
within  the  normal,  either  above  or  below.  A  transient  variation 
of  y2  degree  either  above  or  below  this  point  usually  has  no 
significance. 

During  the  first  week  not  infrequently  infants  develop  a  tem- 
perature of  several  degrees  without  any  apparent  cause,  and 
frequently  without  any  serious  significance,  as  it  often  reaches 
the  normal  again  within  a  few  hours.  It  is  probable  that  the 
lack  of  fluid  and  the  introduction  of  food  and  bacteria  into  the 
intestinal  tract  may  temporarily  interfere  with  the  heat  centres, 
resulting  in  an  increased  production  or  a  diminished  dissipation, 
or  both  combined.  The  proper  place  to  take  the  temperature  is 
the  rectum  (Fig.  23).  Temperatures  taken  in  the  groin,  or 
under  the  arm,  are  inaccurate,  and  if  the  skin  is  moist  the  ther- 
mometer will  not  register. 

Before  taking  the  temperature  care  should  be  taken  to  shake 
the  thermometer  down  below  normal.  It  should  then  be  anointed 
with  vaseline  and  inserted  into  the  rectum  beyond  the  mercury 
bulb.  The  time  necessary  to  take  the  temperature  will  vary  with 
the  make  of  the  thermometer  (2-5  minutes).  Great  care  must 
be  taken  that  with  a  struggling  child  the  thermometer  is  not 
broken  in  the  rectum,  thereby  producing  possible  serious  injury. 


58 


Fig.  23.— Taking  the  temperature  by  the  rectum- 


CHAPTER  VIII 

THE  GROWTH  AND  DEVELOPMENT  OF  THE 
CHILD 

There  is  considerable  variation  in  the  weights  of  individual 
children  at  birth.  Children  born  of  large  parents  are  liable  to 
be  larger  than  those  born  of  small  parents.  When  the  parents 
are  healthy  and  the  mother  well  nourished,  babies  at  birth  are 
liable  to  average  higher  than  if  the  mother  is  badly  nourished. 

Average  Weight  at  BniTii. — After  weighing  many  thou- 
sands of  healthy  infants  at  birth,  it  has  been  found  that  the 
average  weight  for  boys  is  about  seven  and  one-half  pounds,  and 
for  girls  about  seven  pounds. 

Weight  of  Twins. — In  case  of  twins  the  combined  weight 
of  the  two  usually  somewhat  exceeds  the  average  weight  of 
single  births.  One  twin,  however,  is  liable  to  weigh  consider- 
ably more  than  the  other,  although  it  is  not  uncommon  that  they 
are  nearly  equal. 

Loss  OF  Weight  During  the  First  Weeks. — During  the 
first  two  weeks  there  is  usually  some  loss  in  weight,  varying  from 
.a  few  ounces  to  one  pound.  This  loss  in  weight  is  due  to  several 
factors.  There  is,  first  of  all,  the  vernix  cascosa,  which  is  re- 
moved by  the  first  bath.  The  infant  usually  passes  urine  soon 
after  birth,  and  the  meconium  is  passed  in  considerable  amount 
during  the  first  few  days.  Combined  with  the  considerable  loss 
in  weight  from  these  factors,  the  new-bom  receives  little  or  noth- 
ing from  the  mother  during  the  first  day  or  two,  and  not  sufficient, 
oftentimes,  until  the  end  of  the  first  week,  or  even  longer. 

The  loss  in  weight  during  the  first  week,  then,  may  be  re- 

6r 


GROWTH  AND  DEVELOPMENT  6l 

garded  as  physiological,  and  no  concern  need  usually  be  felt 
unless  the  loss  persists  beyond  the  second  week.  If,  however, 
the  baby  shows  evidence  of  prostration,  means  should  be  taken 
to  determine  the  amount  of  milk  it  is  receiving  by  weighing  be- 
fore and  after  nursings. 

Gain  in  Weight  During  the  First  Year. — The  relative 
gain  in  weight  and  body  measurements  during  the  first  year  is 
enormous.  For  example,  an  infant  weighing  seven  and  one-half 
pounds  at  birth  should  at  six  months  double  this  weight,  and 
at  one  year  treble  its  weight.  In  other  words,  an  infant  weigh- 
ing seven  and  one-half  pounds  at  birth  should  weigh  approxi- 
mately fifteen  pounds  at  six  months  and  twenty-one  pounds  at 
the  end  of  the  first  year. 

Increase  in  Measurements. — During  this  time  there  is  a 
correspondingly  rapid  increase  in  the  measurements.  For  ex- 
ample, the  average  height  of  a  male  infant  at  birth  is  about 
twenty  inches  ;  at  the  end  of  the  first  year  it  is  about  twenty- 
nine  and  one-half  inches — a  gain  of  over  nine  inches.  The  cir- 
cumference of  the  head,  which  at  birth  is  about  thirteen  and  one- 
half  inches,  is  almost  eighteen  inches  at  the  end  of  the  first  year, 
being  a  greater  increase  than  during  the  remainder  of  the  life 
of  the  individual. 

Other  Measurements. — During  the  first  two  years  there  is 
a  remarkable  uniformity  in  the  increase  in  size  of  the  head  and 
chest.  At  birth  the  circumference  of  the  head  is  13.8  inches, 
that  of  the  chest  13.1.  At  the  end  of  the  first  year  the  circum- 
ference of  the  head  is  17.9  inches,  that  of  the  chest  17.9  inches, 
and  at  the  end  of  the  second  year  19. i  and  19.5  inches,  re- 
spectively. 

The  maximum  normal  measurement  of  the  head  at  five  years 
equals  the  minimum  adult  measurement.  The  following  chart 
gives  the  average  increase  in  growth  of  the  infant  from  birth  to 
the  sixteenth  year. 


62  CARE  OF  INFANTS  AND  CHILDREN 


Head 


Chest 


Weight.  Height,  circum-  t^eadtk 

'Boys 7.47  20.1  13.8  13.0 

Birth      \ 

(Girls 7.13  19.9  13.3  12.4 

fBoys 16.0  25.4  16.5  16.6 

6  mos.  \ 

[Girls 15,5  25.0  16.5  15.6 

fBoys 21.2  29.2  17.9  17.9 

12  mos.  -j 

[Girls 20.4  28.7  17.9  18.2 

[Boys 22.8  30.0  18.5  18.5 

18  mos.  \ 

[Girls 22.0  29.7  18.0  18.2 

[Boys 28.4  33.1  19. 1  19.5 

2  yrs.    < 

[Girls 27.8  32.7  18.3  18.2 

[Boys 33.5  36.0  19.3  20.1 

3  yrs.    i 

[Girls 31.5  35.6  19.0  19.8 

[Boys 36.4  38.6  19.7  20.7 

4  yrs.    \ 

[Girls 35.1  38.4  19.5  20.5 

[Boys 41.4  41.7  20.3  21.5 

5  yrs. 

[Girls 40.2  41.3  19.9  21.2 

fBoys 45.1  44.0  20.0  23.2 

6  yrs.    i 

[Girls 43.6  43.4  19.8  22.8 

[Boys 49.5  46.1  20.0  23.7 

7  yrs.    \ 

[Girls 47.8  45.8  20.0  23.3 

[Boys 54.5  48.5  20.5  24.4 

8  yrs.    \ 

[Girls 52.2  47.8  20.2  23.8 

[Boys 59.8  50.0  20.6  25.1 

9  yrs.    \ 

[Girls 57.4  49.6  21.2  24.5 

[Boys 66.0  52.0  20.6  25.8 

10  yrs.    I 

[Girls 63.0  51.7  20.5  24.7 


GROWTH  AND  DEVELOPMENT  63 

Head       chp-^t 
Weight.       Height,     circum-  ^Sh 
terence. 

[Boys 71.5  53.8         20.S         27.2 

11  yrs.    < 
[Girls 69.9  53.8         20.7         25.8 

[Boys ; 78.8  55.6         21.0         27.5 

12  yrs.    i 
[Girls 80.0  56.6         2cr.g         26.8 

("Boys 86.0  57.8         2 1. 1         27.7 

13  yrs.    \ 
(Girls 89.9  58.6         21.5         28.5 

Boys 97.2  60.5         21.3         28.8 

Girls 99.3  60.3         21.3         30.0 

fBoys 104. 1  62.9         22.2         30.5 

15  yrs.    •! 

[Girls 107.5  61.5         22.0         31.0 

From  the  foregoing  chart  is  vyill  be  seen  that  the  following 
gains  in  weight  and  length  are  made  by  the  average  child  dur- 
ing the  first  ten  years. 

Gain  in  weight.  Gain  in  length, 
pounds.  inches. 

First  year 133^  9^ 

Second  year y}4  2>H 

Third  year 5  3 

Fourth  year 3  2}4 

Fifth  year 5  3 

Sixth  year 3 j  +  2>^    • 

Seventh  year 4>^  2 

Eighth  year 5  2}4 

Ninth  year 6  2 

Tenth  year 5>^  2 

Up  to  the  eleventh  year  the  gain  in  weight  and  height  of  boys 
and  girls  is  about  uniform,  the  weight  of  girls  being  from  one 
to  one  and  one-half  pounds  less  than  boys,  and  the  height  being 
also  slightly  less. 

Gain  During  Puberty. — ^From  the  eleventh  to  the  fifteenth 
year  girls  gain  faster  in  weight  than  boys,  but  after  adoles- 
cence has  been  well  established  the  boys  again  forge  ahead  of  the 
girls,  both  in  weight  and  height,  and  maintain  this  superiority 
throughout  the  active  period  of  life. 


64 


CARE  OF  INFANTS  AND  CHILDREN 


MuscLK  DiiVKLOPMF.NT. — The  muscles  at  birth  are  poorly 
developed,  with  the  exception  of  more  or  less  incoordinate  move- 
ments of  the  arms,  legs,  and  eye  muscles.  The  development  of 
the  muscles  takes  place  rapidly,  and  the  number,  force,  and  pre- 
cision of  the  movements  soon  become  apparent. 

The  following  table  gives  the  average  time  of  development 
of  the  muscular  functions.  It  must  be  understood  that  with  this 
development  there  is  also  a  corresponding  development  of  the 
bones  and  ligaments,  as  well  as  of  the  nervous  system,  without 
which  any  muscular  movements  are  impossible. 


Remarks. 


Lying  on  back  with- 
out help. 


Withoug  propping 
or  assistance. 

Alone. 

Alone. 

Without  taking  hold 
of  anything. 


TABLE  GIVING  THE  TIMES  AT  WHICH  THE  DIFFERENT  BODILY 

MOVEMENTS  ARE  DEVELOPED    (AFTER   PREYER) 

Movements.       First  attempt.      Well  established. 

Turning  head 4th  day  i6th  week 

Holding  up  head  ...11  weeks  1 6  weeks 

Grippingwithhands.  117  days  19  weeks 

Raising  upper  part 

of  body 16  weeks  22  weeks 

Indicating         v/ith 

hands 8  months  9  months 

Sitting 14  weeks  42  weeks 

Standing 23rd  week         48  weeks 

Walking 41  weeks  66  weeks 

Getting  up  alone ...  28  weeks  70  weeks 

Walk  over  the  door- 
step   68  weeks  70  weeks  

Kissing 12  months         23  months         

Climbing 26  months         7"]  months         

Jumping 27  months         28  months         Without  hesitation 

and  any  help. 

The  foregoing  statements  must  be  considered  only  as 
averages,  always  remembering  that  there  are  exceptions  to  every 
rule. 

Talking. — The  development  of  speech  (articulation)  is  usu- 
ally very  slow,  although  there  is  a  great  variation  in  the  time 
at  which  different  children  begin  to  talk.  Speech  is  always  long 
preceded  by  an  understanding  of  what  is  said  to  the  child  and 
what  it  wishes  to  say  in  retum. 


GROWTH  AND  DEVELOPMENT  65 

At  the  ninth  or  tenth  month  infants  hcgin  to  say  "  Mamma," 
"  Papa,"  hut  will  not  usually  repeat  these  syllables  after  the 
mother  or  nurse  before  the  eleventh  month. 

By  the  fifteenth  to  eighteenth  month  the  child  will  frequently, 
when  told,  close  its  eyes,  indicate  where  the  watch  is,  or  its  eyes 
or  ears,  *'  pat-a-cake,"  etc.  At  the  beginning  of  the  third  year 
children  are  frequently  able  to  form  short  sentences,  but  it  is 
usually  not  before  the  thirteenth  to  thirty-sixth  month  that  such 
sentences  as  "  Please  give  me  a  piece  of  bread  "  can  be  clearly 
spoken. 

Many  children  have  difficulty  for  a  long  time  in  pronouncing 
vv^ords  beginning  C,  G,  J,  K,  L,  Tr.^  If  a  child  does  not  begin  to 
speak  by  the  end  of  the  second  year  he  should  have  a  careful 
examination  for  deafness  or  other  signs  of  defective  physical 
or  mental  development. 

Significance  of  Weight  and  Measurements 

In  order  to  determine  definitely  whether  a  child  is  gaining 
properly  in  weight  it  should  be  weighed  weekly  during  the  first 
year.  A  normal  baby  on  breast  milk  should,  after  the  first  week 
or  ten  days,  gain  steadily  in  weight.  The  weekly  gain  during 
the  first  six  months  should  average  about  six  ounces  per  week, 
or  about  one  and  one-half  pounds  per  month,  so  that  the  weight 
at  six  months  will  be  about  double  that  at  birth.  During  the 
second  six  months  the  gain  in  weight  is  not  quite  so  rapid, 
averaging  normally  about  four  ounces  per  week,  or  one  pound 
per  month,  so  that  at  the  end  of  the  first  year  the  weight  will  be 
approximately  three  times  that  at  birth,  or  twenty-one  or  twenty- 
two  pounds.  The  average  gain  of  eight  ounces  per  week,  as 
generally  given  in  the  text-books,  is  too  high  and  is  the  source 
of  much  confusion,  for  if  an  infant  should  gain  eight  ounces 
per  week  for  the  first  six  months  it  would  weigh  nineteen  and 

*  Preyer,  Die  Seele  des  Kindes. 
5 


66  CARE  OF  INFANTS  AND  CHILDREN 

one-half  pounds  at  six  months  and  twenty-nine  pounds  at  one 
year — an  amount  which  is  universally  considered  by  authorities 
as  decidedly  above  the  normal. 

It  is  not  infrequent  that  in  normal  infants  the  weekly  gain  in 
weight  wnll  not  be  altogether  uniform  ;  for  example,  the  gain  one 
week  may  be  four  ounces,  and  the  next  eight — making  an  average 
of  six  ounces. 

Significance  of  the  Weekly  Gain  in  Weiciit. — When 
the  weight  Remains  at  a  standstill  for  several  weeks  there  is 
something  lacking  in  the  baby  itself  or  in  the  quantity  or  quality 
of  the  food. 

Tech  NIC  of  Weighing. — Babies  should  be  weighed  at  the 
same  time  during  the  day ;  in  the  morning  directly  before  or 
after  the  bath  is  the  most  convenient  time.  The  same  relative 
time  to  the  feedings  should  be  pursued,  as  a  child  weighed  one 
time  before  a  feeding  and  the  next  time  after  would  hardly  give 
a  fair  estimate  of  the  weekly  gain.  In  conjunction  with  the 
weighing  the  other  measurements  of  head,  chest,  and  length 
should  be  made  monthly,  always  having  in  mind  that  therq  are 
considerable  variations  within  the  normal  in  the  individual  child. 
A  record  of  weights  and  measurements  should  be  kept,  as  they 
may  be  of  great  value  to  the  physician  in  the  event  of  illness 
which  may  later  develop. 

The  normal  weight  curve,  which  to  the  average  mother  is  the 
all-important  thing,  is,  however,  only  a  portion  of  the  require- 
ments of  a  normal  child.  Going  hand  in  hand  with  the  normal 
weight  and  measurements,  there  must  be  a  normal  development 
of  the  different  tissues  and  organs.  The  baby  must  have  a 
healthy  rosy  color  of  the  skin  and  mucous  membranes.  There 
must  be  a  proper  tone  to  the  muscles  and  the  bones  must  show 
evidence  of  proper  development. 

Infants  who  are  fat  and  who  may  enjoy  the  distinction  of 
having  their  pictures  on  the  bill-boards,  advertising  some  patent 
food,  may  nevertheless  be  pale,  flabby,  and  suffering  from 
rickets. 


GROWTH  AND  DEVELOPMENT 


(y-i 


For  weighing  children  it  is  important  to  have  accurate  scales 
(Figs.  24  and  25),  as  mistakes  in  the  baby's  weight,  particularly 
if  there  is  an  apparent  loss,  are  liable  to  produce  a  panic  in  the 


Fig.  24 


Fig.  25 


Pigs.  24  and  25. — Scales  for  weighini?  babies  and  older  children. 

household.    The  cheap  dial  scales,  which  depend  upon  the  recoil 
of  a  spring,  are  usually  incorrect. 

The  Weight  Chart. — A  weight  chart  (Fig.  26)  is  a  proper 
means  of  keeping  the  weights  during  the  first  year.  This,  how- 
ever, is  not  indispensable  and  the  weekly  records  may  be  kept  in 
a  book,  or  on  a  card  kept  for  that  purpose. 


68 


CARE  OF  INFANTS  AND  CHILDREN 


The  Teeth 
The  teeth  arc  in  the  jaws  at  birth,  but,  of  course,  undeveloped. 
Tlie  teeth  develop  with  the  other  bony  structures,  and  when  the 
average  baby  is  about  eight  months  old  the  first  teeth  appear 
through  the  surface  of  the  gums.  There  are  many  exceptions 
when  babies  have  teeth  much  earlier  than  eight  months,  and  there 


WEIGHT  CHART. 
Name, Date  of  Birth,. „ 7^ 

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MONTH  OF  AGE. 

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10890 
10130 

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Fig.  26. — The  weight  curve  of  the  first  year. 

are  cases  on  record  in  which  infants  have  been  born  with  teeth. 
This,  however,  is  the  exception. 

The  First  Teeth. — The  first  teeth  to  ap])ear  are  usually  the 
lower  central  incisors,  then  the  two  upper  central  incisors.  The 
next  in  order  are  the  two  upi)er  lateral  incisors.  At  one  year  the 
baby  has  normally  six  teeth.  The  order  of  the  normal  eruption 
of  the  milk  or  deciduous  teeth  is  given  in  the  following  table  : 


GROWTH  AND  DEVELOPMENT  69 

TIME  OF  ERLTTIOX  OF  THE  DECIDUOUS  TEETH 

1.  Two  lateral  central  incisors Six  to  nine  months. 

2.  Four  upper  incisors I'Jght  to  twelve  months. 

3.  Two  lower  lateral  incisors  and   four 

anterior    molars Twelve  to  fifteen  months. 

4.  Four  canines   (stomach  teeth) Eighteen  to  twenty-four  months. 

5.  Four  posterior  molars Twenty-four  to  thirty  months. 

At  one  year,  a  child  should  have  6  teeth. 

At  one  and  one-half  years 12  teeth. 

At  two  years   16  teeth. 

At  two  and  one-half  years 20  teeth. 

It  must  be  remembered  that  these  are  averages  and  that  there 
are  many  variations  within  the  normal. 

Marked  delay  or  irregularity  in  cutting  the  teeth  is  usually 
due  to  rickets  or  some  other  form  of  malnutrition. 

Effects  of  Illness. — In  children  suffering  from  malnutri- 
tion, or  who  have  suffered  from  some  acute  disease,  such  as 
measles  or  scarlet  fever,  the  teeth  are  frequently  lacking  in 
enamel  when  they  come  through  the  gums,  and  are  liable  to 
decay  during  the  first  years. 

The  milk  teeth  should  remain  intact  until  the  seventh  or 
eighth  year,  when  they  are  gradually  replaced  by  the  permanent 
teeth. 

SYMPTOMS  ARISING  FROM  CUTTING  OF  THE  TEETH 

Like  the  liver  in  adults,  the  teeth  in  children  have  been  blamed 
for  all  the  ills  to  which  infancy  is  heir. 

The  fact  is  that  most  infants  cut  their  teeth  without  any  symp- 
toms whatever. 

In  a  small  percentage  of  cases,  especially  in  those  of  a  nervous 
temperament,  there  are  some  slight  symptoms  which  may  be  at- 
tributed to  teething.  The  process  of  cutting  teeth  is  a  con- 
tinuous one  extending  over  the  first  two  and  one-half  years. 

Severe  symptoms,  attended  by  high  fever,  vomiting,  diarrhoea, 
must  therefore  never  be  attributed  to  teething,  etc.,  but  to  some 
other  cause. 


70 


CARE  OF  INFANTS  AND  CHILDREN 


It  occasionally  hajipens  that  before  the  crown  of  a  tooth  ap- 
pears on  the  free  surface  of  the  gums  there  is  some  slight  local 
redness,  the  baby  may  be  fretful,  drool  much,  and  have  some 


Fig.   27. — Temporary  or  milk  teeth;     1,  central  incisor;   2,  lateral    incisor;    3,    canine 
or  eye  tooth;  4,  first  molar;  5,  second  molar. 

slight  fever,  or  the  stools  may  be  somewhat  loose.  In  such 
cases  the  food  should  be  diluted  one-third  to  one-half  with  water 
for  a  day  or  two,  and  if  the  baby  is  nervous  a  warm  bath  at  bed- 
time will  often  result  in  a  relief  of  the  nervous  tension. 

I  I 


Fig.  28. — Permanent  teeth;  1.  central  incisor;  2,  lateral  incisor;  3,  canine;  4,  first 
bicuspid;  S,  second  bicuspid;  6,  first  molar;  7,  second  molar;  8,  third  molar  or  wisdom 
tooth 

It  is  rarely  necessary  to  lance  the  gums  over  the  crown  of  a 
tooth.  This,  however,  in  the  individual  case  must  be  left  to  the 
judgment  of  the  physician. 


GROWTH  AND  DEVELOPMENT 


71 


Fig.  29. 


Fig.  30. 


Fig.  29. — Front  view  of  the  upper  and  lower  models  of  a  child  l.S  years  of  age.  .show- 
ing irregular  teeth  and  retarded  bone  development,  especially  in  the  maxillary  region. 
This  child  had  constricted  nasal  passages.   (Dr.  G.  B.  Steadman.) 

Fig.  30. —  Front  view  of  upper  and  lover  models  of  same  child  14  years  of  age, 
after  orthodontic  treatment  of  one  and  one-half  years.  Nasal  breathing  was  very  rnuch 
improved  by  the  expansion  of  the  dental  arches  and  development  of  bone.  (Dr.  G.  B. 
Steadman.) 


CARE  OF  INFANTS  AND  CHILDREN 


THE  PERMANENT  TEETH 

By  the  time  a  child  is  six  years  old  the  jaws  have  so  developed 
that  there  is  room,  in  addition  to  the  temporary  set  of  twenty 
teeth,  for  four  more.  These  appear  behind  the  temporary 
molars  at  the  angle  of  the  jaw,  one  on  each  side  above  and  be- 
low. At  six  years  a  child  should  have  twenty- four  teeth,  four  of 
which  are  permanent.  At  seven  or  eight  years  the  central  and 
lateral  incisors  become  loose  and  are  replaced  by  the  permanent 


Fig.  31. — Hutchinson  teeth. 

teeth,  which  are  usually  larger  and  frequently  serrated  on  the 
cutting  edge  (Fig.  28).  The  four  bicuspids  replace  the  first 
molars. 

Irregularities  of  the  Permanent  Teeth. — When  there  is 
an  undeveloped  condition  of  the  jaws,  which  frequently  happens 
either  as  a  result  of  congenital  defect  or  mouth-breathing,  the 
space  left  for  the  canine  teeth  is  insufficient,  so  that  the  teeth 
are  crowded  out  of  their  natural  position  in  the  arch.  Ir- 
regularities of  the  teeth  are  very  common,  but  with  the  special 
knowledge  and  appliances  the  modem  dentist  is  able  to  correct 
even  extreme  irregularities.    These  corrections  should  be  made 


GROWTH  AND  DEVELOPMENT 


73 


early,  while  the  bones  are  still  soft  (Figs.  29  and  30).  The  teeth 
in  congenital  syphilis  are  said  to  be  of  characteristic  shape 
(Hutchinson  teeth),  in  which  there  is  a  peculiar  notching  of  the 
upper  central  incisors.  The  condition  is,  however,  not  neces- 
sarily characteristic  of  syphilis  ( Fig.  31 ) . 

CARE  OF   THE  TEETH 

As  soon  as  the  teeth  are  through  the  gums  they  should  be  kept 
clean. 

As  long  as  children  are  on  an  exclusive  milk  diet  there  is 
rarely  any  amount  of  deposit  on  the  teeth.  They,  however, 
should  be  cleansed  daily  with  a  soft  brush  wet  with  an  alkaline 
solution  (Seller's). 

At  three  years  a  child  should  be  taught  to  brush  its  own  teeth. 
The  space  between  the  teeth  should  be  kept  free  of  food  by 
dental  floss.  Discoloration  on  the  teeth  should  be  removed  with 
some  good  tooth  powder,  and  if  this  is  impossible  the  child  should 
be  taken  to  a  dentist.  The  tooth-brush  should  be  washed  in 
running  water  after  using.  Otherwise  it  becomes  foul  and  may 
do  more  harm  than  good. 

A  child's  teeth  should  be  looked  over  by  a  dentist  every  six 
months  and  all  cavities  filled. 

EFFECTS  OF  DECAYED  TEETH 

Decayed  teeth  are  undoubtedly  the  cause  of  many  ills  from 
which  children  sufifer.  Many  fonns  of  bacteria  are  harbored  in 
the  cavities  of  decayed  teeth,  as  well  as  food,  which  rapidly 
undergoes  decomposition.  This  becomes  mixed  with  the  food, 
producing  serious  digestive  disturbances. 

Inflammation  of  the  gums,  and  even  abscesses  at  the  roots 
of  the  teeth,  are  common.  Such  accumulations  of  pus  are 
rapidly  absorbed  into  the  lymphatic  channels,  resulting  in  en- 
larged glands,  tonsillitis,  and  serious  systemic  poisoning.  The 
normal  character  of  the  permanent  teeth  is  frequently  greatly 
impaired  both  by  the  local  infection  of  the  temporary  teeth,  and 
by  the  effects  of  the  generally  lowered  vitality. 


CHAPTER  IX 

CLOTHING  FOR  INFANTS 

The  following  list  of  clothing  is  appropriate  for  a  young 
baby.  Fewer  articles  may  be  provided,  but  more  frequent  laun- 
dering will  be  necessary. 

Two  to  five  dozen  diapers,  20  by  24  inches.  These  should  be 
of  soft  cotton  material. 

Four  to  six  shirts;  soft  woollen,  or  cotton  and  wool,  or  silk 
and  wool.  For  hot  weather  the  shirts  should  be  of  the  thinnest 
wool,  and  if  the  weather  is  extreme  they  may  be  of  cotton. 

Six  bands,  flannel  or  knitted,  6  to  8  inches  wide.  During 
the  hot  weather  they  may  be  discarded  if  a  thin  woollen  skirt  is 
worn. 

Six  skirts,  flannel.  During  hot  weather  cotton  or  muslin 
should  be  worn. 

Six  night-gowns,  of  outing-flannel  or  cotton  (for  summer). 
They  should  be  long  enough  to  pucker  with  draw-strings  at  the 
bottom  over  the  feet,  and  large  enough  not  to  interfere  with  the 
movement  of  the  legs. 

One  dozen  dressing  slips,  of  simple  wash  material  of  various 
weights.  Expensive  linens  with  embroidery  are  only  for  the 
rich.  There  is  no  good  reason  for  the  length  extending  beyond 
the  feet. 

Three  blankets,  or  comforts,  of  various  degrees  of  warmth 
for  different  weather. 

Two  knitted  sacks. 

Six  to  eight  quilted  pads  for  the  basket  or  bed. 

One  cloak. 

Two  caps :  one  warm,  one  cool. 

Two  veils,  without  color. 

Two  rubber  blankets,  one  yard  square. 

One  hair  pillow,  10  by  12  inches,  i  to  2  inches  thick. 

Six  pillow  covers. 

Six  sheets. 
74 


CLOTHING  FOR  INFANTS 


75 


For  stretching  stockings  and  shirts  after  washing,  an  appro- 
priate stretcher. 

Ohj>'^<-"1'  of  Clotiiinh'.. — In  dressing  young  infants  the  great- 
est judgment  is  required.  The  first  thing  to  remember  is  that 
clothes  are  primarily  for  warmth.  In  very  hot  climates,  and 
in  temperate  climates  at  times,  clothing  is  worn  only  to  cover 
nakedness — in  other  words,  for  appearance. 


Fig.  32. — Diaper  pinned  in  the  proper  manner. 

Where  the  temperature  is  so  variable  as  it  is  in  the  northern 
parts  of  this  country,  the  amount  and  kind  of  clothing  must 
necessarily  vary  greatly. 

Young  infants  do  not  accommodate  themselves  readily  to 
sudden  and  extreme  changes  either  of  heat  or  cold.  Infants, 
if  exposed  to  cold,  lose  heat  rapidly,  and  are  liable  to  suffer 
from  catarrhal  inflammation  of  the  respiratory  or  digestive 
tracts.     If  they  are  exposed  for  any  considerable  time  to  ex- 


76 


CARE  OF  INFANTS  AND  CHILDREN 


cessive  heat,  the  body  temperature  is  liable  to  be  above  normal, 
and  they  are  likewise  liable  to  catarrhal  inflammation  of  the 
digestive  and  respiratory  tracts.  The  clothing  must  therefore 
be  changed  according  to  the  temperature. 

Prickly  Heat  as  Result  of  Much   Clothing. — Young 
infants  must  be  dressed  so  that  they  are  comfortable,  but  not 


Fig.  33. 


Fig    3i. 


Fig.  33. — Waist  with  broad  shoulder  straps  fitting  well  up  against  the  neck.  (Good.) 
Fig.   31. — Waist   with   narrow   straps   which  fall  out  on  the  points  of  the  shoulders, 
thereby  tending  to  pull  them  downward  and  forward.     (Bad.) 

so  warm  that  the  skin  is  wet  with  perspiration.  In  hot 
weather  much  of  the  clothing  should  be  removed.  It  is  a  com- 
mon thing  to  see  infants  with  so  much  clothing  that  they  cry 
incessantly,  the  skin  being  covered  with  prickly  heat  and  the 
temperature  several  degrees  above  normal,  and  in  addition 
they  may  have  vomiting  and  diarrhoea. 

Tight  Clothing. — The  clothing  about  the  chest  and  abdo- 


CLOTHING  FOR  INFANTS 


17 


men  should  be  sufficiently  loose,  so  as  not  to  impede  either  the 
respiratory  or  digestive  functions.  Tight  clothing,  or  bands, 
about  the  abdomen,  is  a  common  cause  of  regurgitation  of  food. 
Under  Garments. — A  form  of  under  garments,  including 
diapers,  known  as  "  Vanta  Garments."  are  tied  with  tapes  in- 
stead of  buttons  or  safety-pins,  and  they 
are  an  improvement  over  the  ordinary 
varieties.  It  is  not  uncommon  that  in 
the  application  of  diapers  with  the  or- 
dinary safety-pins  the  skin  is  also  in- 
cluded. When  a  baby  shrieks  as  if  in 
pain,  it  is  always  advisable  to  see  if  a 
pin  may  not  be  the  exciting  cause. 

In  pinning  the  diaper  to  the  shirt,  one 
must  be  careful  not  to  pin  it  too  high, 
producing  undue  tension  on  the  shoul- 
ders,   thereby    causing    deformity     (see 

Fig.  32). 

Diapers  should  be  removed  as  soon  as 

soiled  and  never  used  again  until  washed 

and  boiled. 

As  soon  as  children  are  able  to  run 

about  the  clothing  should  be  suspended 

from  the  shoulders,  and  never  from  the 

waist.     The  exact  manner  in  which  the 

clothing  is  suspended  from  the  shoulders 

is,  however,  of  the  greatest  importance. 
Suspending    Clothing    from    the 

Shoulders. — The    best    manner    is    by 

means  of  a  properly  constructed  w'aist, 

upon  which  most  of  the  other  clothing  is  fastened.    Fig.  33  shows 

an  ideal  pattern  with  broad  shoulder  straps  fitting  well  up  against 

the  neck,  thereby  equalizing  the  weight  over  the  entire  shoulder. 

The  ordinary  variety  purchased  in  the  shops    (Fig.   34)    has 

narrow  straps  which  usually  fall  well  out  on  the  points  of  the 


Fig.  35. — Blanket  wrap 
for  cold  weather.  (Miss 
Rena  P.  Fox,  Babies'  Hos- 
pital, Philadelphia.) 


78 


CARE  OF  INFANTS  AND  CHILDREN 


shoulders,  thereby  tending  to  drag  them  downward  and  forward. 
Clothing  Within  Doors. — For  the  average  well-heated 
house  in  this  country,  the  underclothing  should  not  be  of  very 
heavy  weight.  A  light  woollen  shirt  and  drawers  for  winter 
in  the  northern  climate  is  usually  sufficient,  with  a  warm  woollen 
coat   for   out   of   doors.      Many   children   are    far   too   warmly 


Fig.  36. — Improper  shape  of  sole  of  child  shoe,  and  proper  shape.   (Rotch's  Pediatrics.) 

dressed  while  within  doors,  and  are,  as  a  result,  rendered  very 
susceptible  to  cold  when  they  venture  out.  When  children  are 
old  enough  to  kick  the  bedclothes  off  at  night,  it  is  better  1o 
wear  warm  clothing,  such  as  a  sweater,  leggins,  cap,  and  even 
mittens,  than  to  depend  entirely  on  blankets. 

A  very  light  weight  shirt  of  wool,  or  cotton  and  wool,  even 


CLOTHING  FOR  INFANTS 


79 


in  summer,  in  the  north,  will  be  found  to  protect  children  from 
the  sudden  changes  of  the  temperature  and  from  becoming 
chilly  after  vigorous  play. 

When  children  are  out  of  doors  in  cold  weather,  not  only  is 
it  necessary  to  keep  the  body  warm,  but  the  feet,  legs,  and  hands 
must  also  be  kept  warm.  Children  will  not  play  out  of  doors 
in  cold  weather  unless  they  are  comfortably  dressed.  Over- 
shoes and  woollen  over-stockings  should  be  provided  which 
can  be  removed  when  within 
doors. 

Dangers  of  Being  Frost- 
bitten IN  Cold  Weather. — 
The  greatest  care  must  be  ex- 
ercised in  wheeling  children 
about  in  cold  weather  that 
they  be  warmly  clothed.  The 
attendant  may  be  thoroughly 
warm,  while  the  baby  may  be 
nearly  frozen  to  death  and  yet 
be  unable  to  express  itself  in 
appropriate  language,  other 
than  by  crying  (Fig.  35).  p^^  3^ 

Young  children  should  not 
be  taken  out  in  zero  weather,  and,  if  they  are  taken  out,  their 
faces  should  be  covered,  as  they  are  frequently  frost-bitten  if 
exposed  only  for  a  few  minutes. 

Shoes. — Shoes  should  be  comfortable,  allowing  the  feet 
plenty  of  room  (Fig.  36).  Cramping  of  the  toes  should  be 
absolutely  prohibited.  Shoes  without  heels  should  be  worn  for 
several  years,  and  high  he'els  should  never  be  worn,  as  they  tip 
the  body  out  of  line  and  are  liable  to  produce  breaking  down 
of  the  arches  of  the  feet  by  throwing  an  undue  amount  of  weight 
upon  the  front  part  of  the  foot  (^^S-  37)- 

Sandals  with  broad  toes  are  excellent  for  summer  and  are 
the  next  best  thing  to  going  l)arefoot. 


-Showing  position  of  the  foot  in  a 
high-heeled  shoe. 


CHAPTER  X 

EXERCISES  FOR  INFANTS  AND  CHILDREN 

During  the  first  months  about  the  only  exercise  a  baby  gets 
is  by  moving  his  arms  and  legs  and  crying. 

Unrestricted  action  of  all  muscles  should  therefore  be  per- 
mitted, and  in  no  way  hampered  by  the  clothing.  Daily,  morning 
and  evening,  when  the  baby  is  undressed  it  should  be  encouraged 


Fig.  38. — "  At  si.\   months  the  baby  not  only  lifts  its  head  but  begins  raising  its  body 

on  its  arms." 

to  make  as  free  movements  as  possible.  At  about  three  or  four 
months,  if  a  baby  is  placed  on  the  stomach,  it  will  begin  holding 
up  its  head,  thus  bringing  into  use  the  muscles  in  the  neck  and 
back  (Fig.  38).  At  five  or  six  months,  the  baby  not  only  lifts 
its  head  but  begins  raising  its  body  on  its  anns  and  also  making 
attempts  to  bring  into  use  the  muscles  of  the  thighs,  so  that  by 
the  eighth  or  ninth  month  it  begins  to  raise  itself  on  all-fours 
and  creep  about.  .Such  movements  give  a  wide  range  of  exercise 
80 


EXERCISES  FOR  INFANTS  AND  CHILDREN  8i 


Fig.  39. — Nursery  pen.    (Peer's  "Diseases  of  Children.") 


Fig.  40. — Showing  the  improper  curvature  of  the  spine,  resulting  from  putting  a  young 
baby  in  the  sitting  position. 


82 


CARE  OF  INFANTS  AND  CHILDREN 


to  almost  all  the  muscles,  and  it  will  be  found  that  infants  who 
are  allowed  such  exercise  will  be  much  stronger  than  those  who 
are  kept  constantly  on  their  backs  and  allowed  no  freedom. 
Babies  should  be  allowed  all  the  freedom  of  movements  of 


Fig.   41. — A  young  child  in  a  bad  go-cart. 


which  they  are  capable  (Fig.  39).  These  positions  and  exer- 
cises should  not  be  forced  upon  them,  as  deformity  may  result. 
It  is  important  when  a  baby  begins  to  creep  to  see  that  it  does  not 
use  one  leg  and  one  arm  to  the  exclusion  of  the  other.    A  little 


EXERCISES  FOR  INFANTS  AND  CHILDREN 


83 


Fig.  42.  -A  few  exercises  which  may  be  practised  daily  to  advantage. 


84  CARE  OF  INFANTS  AND  CHILDREN 

encouragement  in  starting  the  baby  off  right  will  usually  suffice 
to  institute  a  proper  gait. 

Effects  of  Erect  Positions. — Young  infants  should  never 
be  placed  in  the  sitting  position  even  when  propped  with  pillows ; 
their  muscles  are  not  sufficiently  developed  to  maintain  the  spinal 
column  in  its  proper  position  and  curvatures  are  apt  to  result 
(Figs.  40  and  41). 

As  soon  as  children  are  old  enough  to  run  about  they  should 
be  out  of  doors  as  much  as  possible.  During  the  summer  months 
they  should  have  a  great  variety  of  occupations,  so  that  when 
they  are  tired  of  walking  they  may  sit,  and  while  resting  one 
group  of  muscles,  may  be  exercising  another,  in  a  sand-pile,  for 
example. 

Unless  there  is  a  good  variety  of  exercises,  children  in  the 
city  are  liable  to  develop  the  leg  muscles  and  leave  the  chest, 
back,  and  arm  muscles  but  poorly  developed. 

A  few  exercises  which  may  be  practised  daily  are  all  that  are 
necessary  in  developing  the  muscles  of  chest  and  arms  (Fig.  42). 

Exercises  for  Older  Children. — Children  should  walk  to 
and  from  school  if  the  distance  is  not  too  great.  The  play  in 
which  the  children  indulge  when  not  restricted  (by  a  governess) 
brings  into  play  most  of  the  muscle  groups  and  for  the  average 
healthy  child  will  meet  all  requirements. 


CHAPTER  XI 
BREAST  FEEDING 

Of  all  the  mammals  the  human  is  the  only  one  which  has 
ever  raised  the  question  as  to  the  necessity  of  nursing  its  own 
young. 

It  has  been  conclusively  demonstrated  that  there  is  but  on^ 
ideal  food  for  infants,  and  that  is  mother's  milk.  In  every 
species  of  mammal  the  mother  secretes  a  milk  peculiar  to  its  own 
kind  and  needs. 

As  will  be  later  shown,  the  character  of  the  milks  of  different 
animals  differs  widely  both  in  the  percentages  of  the  elements 
of  which  they  are  composed  and  in  their  biological  character,  of 
which  we  know  as  yet  but  little. 

After  the  child  is  born,  and  is  separated  from  the  mother  by 
the  cutting  of  the  cord,  it  still  remains  dependent  upon  her  for 
sustenance  for  the  greater  part  of  the  first  year.  Any  food  which 
may  be  offered,  unless  it  be  human  milk,  is  but  a  poor  substitute, 
and  results  in  a  death  rate  seven  to  ten  times  greater  than  when 
the  infant  receives  breast  milk. 

Colostrum. — The  first  secretion  of  the  breast  is  known  as 
colostnmi,  which  is  of  a  light  yellow  color  and  alkaline  in  re- 
action. It  is  richer  than  milk  in  protein  and  salts  and  poorer  in 
sugar  and  fat.  According  to  Longstein,  the  protein  may  be  as 
high  as  6  per  cent,  on  the  first  day  (Fig.  43). 

The  average  composition  of  colostrum  is  given  in  the  fol- 
lowing table   (Camerer)  : 

Per  cent. 

Water     87.9 

Proteins     3.1 

Fats ;i.3 

Milk  sugar  5.3 

Salts   0.4 

85 


86         CARE  OF  INFANTS  AND  CHILDREN 

After  a  few  days  the  character  of  the  secretion  begins  to 
change  and  the  colostrum  is  gradually  replaced  by  the  true  milk. 
This  j^rocess  occupies  from  a  week  to  twelve  days,  and  occa- 
sionally longer. 

Colostrum  has  a  characteristic  appearance  under  the  micro- 
scope quite  different  from  milk.  It  contains  large  cellular  bodies 
called  colostrum  corpuscles,  as  well  as  a  large  number  of  leuco- 
cytes, or  white  blood-cells. 

The  average  percentage  composition  of  human  milk  is  given 
in  the  following  table : 

Water 87.5 

Protein     1.5 

Fat    3-5-4 

Milk  sugar   6.5-7 

Salts   0.2 

These  percentages  vary  considerably  in  different  individuals, 
and  in  the  same  individual  at  different  times,  so  that  from  a 
single  analysis  little  information  of  value  can  be  gained. 

Average  Quantity  of  Milk  in  Breasts. — During  the  first 
few  days  there  is  but  little  secretion  in  the  breasts.  The  average 
daily  secretion  during  the  first  year  as  determined  by  weighing 
the  baby  before  and  after  nursings  is  given  in  the  following  table 
(Camerer)  : 

Gm.  Oz. 

1st    day     10                    ys 

2nd  day    90  3 

3rd  day     190  6y^ 

4th  day  310  10 

>        Sth  day  350  iV/j 

6th  day  390  13 

7th  day     470  132/, 

3rd  week    500  1 6 

4th  week    600  20 

8th  week    800  261^ 

I2th  week    900  30 

24tli  week    1000  32 

From  the  sixth  to  the  twelfth  month  the  secretion  remains 
about  the  same,  going  occasionally  as  high  as  1200  grammes. 


BREAST  FEEDING 


87 


It  not  infrequently  happens  that  the  quantity  of  milk  secreted 
during  the  first  week,  particularly  in  primipara,  is  not  as  much 
as  given  in  the  above  table,  and  there  is  a  certain  percentage  of 
cases,  of  course,  perhaps  larger  in  this  country  than  abroad, 
where  the  quantity  never  reaches  that  amount. 

From  a  large  number  of  observations  during  the  past  ten 
years,  it  has  been  determined  that  fully  po  per  cent,  of  all  mothers 
can  nurse  their  babies  in  zvhole  or  in  part  during  the  first  year. 

The  simple  fact  that  the  mother  has  insufficient  milk  for  the 
baby  is  no  excuse  for  weaning  it.  The  baby  should  have  all 
the  milk  secreted,  and  if  more 
is  required  it  should  be  made 
up  with  properly  diluted  cow's 
milk. 

Reasons  for  Weaning 
THE  Baby.  —  There  are  very 
few  reasons  sufficiently  weighty 
to  excuse  a  mother  from  nurs- 
ing her  baby.  Some  authori- 
ties, notably  German,  admit  of 
only  one,  and  that  is  active 
tuberculosis  in  the  mother. 
There  are  undoubtedly  others,  ^^^-  43.- Colostrum  corpuscles. 

but  they  are  few     Mothers  can  usually  nurse  their  babies  through 
most  illnesses  without  detriment  either  to  mother  or  child. 

Small  Mortality  of  Breast-fed  Babies. — The  mortality 
in  breast-fed  babies  is  only  about  one-seventh  that  of  bottle-fed 
babies.  Even  when  the  amount  of  breast  milk  is  insufficient, 
and  when  the  deficiency  is  made  up  with  other  food,  the  death 
rate  is  much  less. 

During  the  siege  of  Paris,  in  1870,  the  mortality  among  in- 
fants was  lower  than  it  ever  had  been,  owing  to  the  fact  that  it 
was  impossible  to  get  cow's  milk  and  other  foods,  the  mothers 
being  compelled  to  nurse  their  babies. 

Immunity  to  Disease. — Breast-fed  babies  enjoy  a  certain 


88  CARE   OF  INFANTS  AND  CHILDREN 

immunity  to  disease  which  artificially-fed  infants  do  not  possess, 
and  are  much  more  liable  to  recover  when  they  are  attacked.  It 
has  been  pretty  well  demonstrated  that  the  immunizing  prin- 
ciples of  the  mother's  blood  may  be  transmitted  to  the  child 
through  the  milk.  It  is  impossible,  however,  to  transmit  im- 
munity through  the  milk  except  to  the  young  of  the  same  species. 
Many  drugs,  including  cathartics,  are  eliminated  in  the  milk,  caus- 
ing disturbance  in  the  infant. 

Many  of  the  failures  in  breast-feeding  are  due  to  faulty  tech- 
nic.  Almost  all  babies  may  be  kept  on  the  breast  if  the  conditions 
of  the  individual  case  are  carefully  studied. 

Technic  of  Nursing. — During  the  first  twenty-four  hours 
it  is  sufficient  to  put  the  baby  to  the  breast  two  or  three  times. 
If  there  is  little  or  no  secretion,  a  little  boiled  water  may  be  given 
with  a  spoon  (one-fourth  to  one-half  ounce).  If  the  water  is 
given  through  a  rubber  nipple  the  baby  will  frequently  refuse  to 
take  the  breast. 

During  the  second  twenty-four  hours  the  baby  may  be  put 
to  the  breast  every  five  hours ;  during  the  third  day  every  four 
hours,  and  from  the  fourth  day  on,  it  may  have  five  or  six  feed- 
ings in  the  twenty-four  hours,  at  four-  or  three-hour  intervals. 
The  nursings  should  usually  alternate,  giving  first  one  breast, 
then  the  other.  When  the  secretion  of  milk  is  abundant,  an 
infant  may  be  fed  at  four-hour  intervals,  with  but  five  feedings 
in  the  twenty-four  hours.  If  the  milk  supply  is  not  abundant, 
and  it  is  found  after  a  couple  of  weeks  that  the  baby  is  not 
gaining,  the  feedings  may  be  three  hours  apart,  with  five  feed- 
ings during  the  day  and  perhaps  one  at  night,  making  six  dur- 
ing the  twenty- four  hours.  If  the  quantity  is  still  insufficient 
both  breasts  may  be  given  at  each  feeding. 

The  common  mistake  is  made  in  thinking  that  babies  are 
hungry  because  they  cry  and  stick  their  fingers  in  their  mouths, 
when  in  reality  they  are  often  sufifering  from  colic  due  to  over- 
feeding. 

It  is  important,  therefore,  to  know  the  amount  of  milk  the 


BREAST  FEEDING 


89 


infant  is  getting  at  a  meal,  and  more  especially  the  total  quantity 
of  food  taken  during  the  entire  day. 

Weighing  Before  and  After  Nursings. — In  order  to  de- 
termine this  it  will  be  necessary  to  weigh  the  baby  occasionally 
before  and  after  nursing,  the  difference,  of  course,  being  the 
amount  of  milk  taken,  unless  the  baby  has  passed  urine  or  faeces 
and  the  diaper  has  been  changed  in  the  interval. 

If  there  is  vomiting  of  food  long  after  a  meal  and  just  before 
the  next  meal-time,  and  in  addition  if  the  stools  are  curdy 
and  green,  it  is  fair  evidence  in  itself  that  the  baby  is  getting 
too  much  milk.      Under  such  conditions   the   time  of   nursing 


Fig.  44. — English  breast-pump. 

should  be  reduced  until  it  is  found  by  weighing  that  the  baby  is 
getting  the  proper  amount,  or  the  total  number  of  nursings  may 
be  reduced  and  the  time  between  feedings  lengthened.  It  is  fre- 
quently necessary,  if  there  has  been  considerable  digestive  dis- 
turbance which  has  lasted  for  some  days,  to  give  the  baby  a 
complete  rest  from  food  for  several  feedings,  substituting  only 
water  or  barley  water.  During  this  time  the  milk  will  have  to 
be  regularly  pumped  or  expressed  from  the  breasts  (Fig.  44). 
Effect  of  Temper.vment  on  Milk  Secretion. — There  is 
a  great  difference  between  individual  mothers  in  their  milk- 
giving  powers.  Women  of  an  even  temperament  will,  all  things 
being  equal,  secrete  more  milk  and  of  a  more  uniform  quality 
than  those  of  a  neurotic  temix^rament. 


90         CARE  OF  INFANTS  AND  CHILDREN 

Shape  of  Breasts. — There  is  also  a  great  difference  in  the 
secreting  power  of  differently  shaped  breasts.  The  firm,  pear- 
shaped  breast  with  large  prominent  veins,  will  usually  secrete  a 
large  amount  of  milk,  which  will  flow  upon  pressure  from 
several  openings  in  the  nipple.  The  flat,  saucer-shaped  breasts 
and  the  large,  flabby,  pendulous  breasts  will  rarely  exceed  the 
demands  made  upon  them. 

How  TO  Stimulate  a  Flow  of  Milk. — The  best  stimulant 
to  the  secretion  of  milk,  is  a  thorough  emptying  of  the  breasts. 
Many  mothers  will  give  a  very  large  amount  of  milk  if  the 
breasts  are  frequently  and  thoroughly  emptied.  It  is  of  common 
occurrence,  in  children's  hospitals,  to  feed  as  many  as  three 
babies  from  one  wet  nurse,  the  amount  increasing  with  the 
demands.    • 

Colic. — The  most  common  cause  of  digestive  disturbance  in 
breast-fed  babies  is  over-feeding.  Colic  is  simply  another  name 
for  indigestion. 

Over-feeding. — BabieS  who  are  gaining  in  weight,  four  to 
six  ounces  per  week,  are  getting  sufficient  food.  If  there  is 
vomiting  and  the  stools  are  large,  frequent  and  full  of  small 
white  curds,  they  are  over-fed. 

The  rule  should  be,  to  give  as  little  milk  as  possible  and  still 
have  the  baby  gain  a  proper  amount  in  weight. 

Under-feeding. — Occasionally  infants  are  under- fed.  Such 
cases  will  not  gain  in  weight,  the  stools  are  small,  sometimes 
greenish,  but  rarely  curdy.  In  such  cases  it  will  be  found,  by 
weighing  before  and  after  nursing,  that  the  baby  will  not  get 
over  one-half  to  one  ounce  from  both  breasts.  Under  such  con- 
ditions, hozvever,  the  baby  should  not  be  iveaned,  but  given  all 
the  breast  milk  it  can  get,  and  the  remainder  of  the  meal  made  up 
ivith  other  food. 

Reasons  Why  an  Infant  Refuses  to  Nurse. — Occasion- 
ally it  will  be  found  that  a  baby  refuses  to  take  the  breast,  or  if 
it  does  take  hold,  it  quickly  lets  go  and  cries,  and  cannot  again 


BREAST  FEEDING  91 

be  induced  to  make  the  effort.     There  are  several   different 
causes  which  may  produce  these  symptoms : 

1.  An  inabihty  to  breathe  through  the  nose,  and  a  conse- 
quent inabiUty  to  retain  hold  of  the  nipple  because  of  having  to 
open  the  mouth  to  breathe.  The  most  common  causes  of  such 
an  obstruction  in  the  nose  are  adenoids  (large  post-pharyngeal 
tonsil)  and  coryza. 

2.  Undeveloped  or  inverted  nipples. 

3.  Insufficient  milk  in  the  breasts. 

4.  Tongue-tied  infants. 

Under  such  conditions  a  correct  diagnosis  will  make  it 
possible  for  the  physician  to  overcome  the  difficulty. 

Fissured  nipples  are  a  common  cause  of  infections  in  the 
breast,  as  well  as  being  the  source  of  much  discomfort  to  the 
mother.    The  result  is  that  the  baby  is  very  often  weaned. 

Nipple-shield. — After  each  nursing  the  nipples  should  be 
washed  with  a  saturated  boric  acid  solution  or  a  50  per  cent, 
alcohol,  and  if  there  are  fissures  a  nipple-shield  (Fig.  46)  should 
be  worn  at  each  nursing  until  they  are  healed. 

Abscess  of  the  Breast. — It  is  not  necessary  to  wean  the 
baby  in  case  of  abscess  of  the  breast.  The  abscess  should  be 
opened  and  drained  and  the  baby  nursed  at  the  other  breast 
and  the  milk  expressed  from  the  affected  side  regularly  until 
healed,  when  nursing  may  be  resumed  on  that  side.  Such  an 
abscess  usually  involves  only  one  segment  of  a  breast  and  does 
not,  therefore,  destroy  the  breast  function,  as  is  generally 
believed  by  the  laity. 

Diet  of  the  Mother. — The  diet  of  the  nursing  mother  is 
of  great  importance.  The  generally  accepted  belief  that  mothers 
can  eat  but  a  certain  few  things,  otherwise  the  baby  will  have 
colic,  is  nonsense. 

The  mother  should  have  a  good  full  diet,  but  should  not  eat 
foods  which  will  disturb  her  own  digestion.  She  should  not 
eat  between  her  meals  unless  she  is  hungry  ;  otherwise  it  results 
in  disturbing  her  digestion  and  in  insufficient  food  being  eaten 


92 


CARE  OF  INFANTS  AND  CHILDREN 


BREAST  FEEDING 


93 


at  the  regular  meal-time.  Plenty  of  water  should  be  taken 
between  meals,  thus  insuring  a  good  quantity  of  milk  of  average 
quality. 

Mothers  who  drink  large  quantities  of  milk  and  gruels  be- 


FlG.  46. — If  there  are  fissures,  a  nipple-shield  should  be  worn  at  each  nursing. 

tween  meals  are  apt  to  put  on  flesh  rapidly  and  liave  a  scant 
milk  supply,  rich  in  fat. 

Exercise  for  the  Mother. — Regular  exercise  in  the  open 
air  is  of  vital  importance  to  mothers  during  the  nursing  period. 
This  is  particularly  true  of  women  of  nervous  temperament. 

Regular  Hours  for  Nursings. — Regular  hours  for  nursings 
should  therefore  be  instituted  from  the  beginning.    If  a  mother 


94  CARE  OF  liNFANTS  AND  CHILDREN 

knows  the  exact  hour  when  her  baby  is  to  be  fed,  she  can 
arrange  to  get  the  proper  amount  of  sleep  and  recreation,  with- 
out which  no  mother  can  be  really  normal  and  happy.  By 
religiously  following  these  rules,  many  babies  will  be  kept  on 
the  breast  which  otherwise  would  be  weaned.  When  for  any 
reason  a  mother  cannot  nurse  her  baby,  a  wet  nurse  should  be 
provided. 

The  Stools 

Meconium. — The  stools  during  the  first  four  or  five  days 
after  birth  consist  of  a  black  tarry  substance  called  meconium. 
This  is  made  up  of  epithelium  and  other  debris  from  the 
intestinal  tract. 

After  four  or  five  days  the  stools  usually  begin  to  have  a 
yellowish  appearance,  and  by  the  end  of  the  first  week,  if  the 
secretion  of  milk  has  been  well  established,  they  are  of  a  normal 
yellow  color  and  of  the  consistency  of  thick  gruel.  After  a 
few  weeks  they  have  more  consistency  and  are  later  semi-formed. 

During  the  first  week,  before  the  meconium  entirely  disap- 
pears, they  may  have  a  greenish  tinge.  This,  however,  is  not 
what  is  meant  by  green  stools. 

Green  Stools. — Occasional  green  stools  have  no  particular 
significance  in  breast  babies,  if  the  baby  is  gaining  in  weight 
and  otherwise  normal. 

Stools  which  are  greenish  and  full  of  curds  are  usually  due 
to  over- feeding. 

Bad  Effects  of  Cathartics. — The  common  practice  of  giv- 
ing castor  oil  or  other  cathartics  to  infants  should  be  absolutely 
prohibited,  as  should  the  use  of  suppositories  and  injections. 

If  nature  intended  that  infants  should  have  these  things,  they 
would  have  been  born  with  a  supply. 

If  cathartics  are  given,  and  all  the  contents  of  the  bowel 
swept  out,  no  normal  movement  is  possible  until  the  bowel  fills 
up  again.  If  the  bowels  were  left  alone  until  they  moved  of 
themselves,  there  would  be  little  difficulty  with  constipation 
later  on. 


BREAST  FEEDING  '  95 

Regulakitv  or  the  Stools. — No  serious  consequence  will 
follow  if  a  baby  does  not  have  a  movement  daily  during  the 
first  weeks.  If,  however,  the  baby  has  fever  and  the  stools 
are  bad  in  character  a  single  dose  of  castor  oil  (oss  to  oi)  may 
be  given,  but  not  repeated.  The  food  should  be  discontinued  for 
a  few  feedings,  and  boiled  water  given  instead,  after  which  the 
amount  of  food  allowed  should  be  lessened,  to  prevent  a  recur- 
rence of  the  symptoms.  The  cause  of  the  fever  and  bad  stools 
should  be  carefully  looked  for. 

Menstruation  of  the  Mother. — The  re-establishment  of 
menstruation  during  the  nursing  period  has  little  significance, 
except  that  the  milk  is  liable  to  be  scant  for  a  few  days,  and 
occasionally  some  extra  food  may  have  to  be  given  temjx)rarily. 

Pregnancy  of  the  Mother. — Pregnancy  during  the  lacta- 
tion period  is  sufficient  reason  for  gradually  weaning  the  baby. 
It  is  only  fair  to  the  mother,  to  give  her  a  proper  chance  to 
maintain  her  own  nutrition,  as  well  as  that  of  the  foetus.  The 
baby  by  that  time  has  usually  reached  an  age  when  it  can  be  gradu- 
ally put  ujxjn  an  artificial  food  without  any  serious  detriment. 

Mixed  Feeding. — After  a  baby  is  six  or  seven  months  old, 
it  should  have  some  other  food  in  addition  to  breast  milk.  At 
first  it  is  sufficient  to  give  a  little  oatmeal,  well  cooked,  a  litt}e 
toast,  or  a  few  teaspoons  of  soup,  or  beef  juice.  At  nine  months 
it  may  have  a  tablespoon  or  two  of  well-cooked  cereal  (strained) 
or  a  slice  or  two  of  zwieback,  in  addition  to  some  fruit  juice 
during  the  day.  All  extra  food  should  be  given  at  the  meal- 
time, and  nothing  between  but  a  little  water  (one-half  to  one 
ounce).  It  will  usually  be  found  that  babies  who  have  been  fed 
some  extra  food  after  the  seventh  month  will  be  better  nourished 
at  a  year  than  those  who  have  been  fed  exclusively  on  milk. 

Weaning. — A  baby  should  be  entirely  weaned  at  the  age 
of  one  year.  It  is  better  to  do  this  gradually,  beginning  by  giving 
one  bottle  instead  of  a  nursing,  then  two,  so  that  at  the  end  of  a 
month  or  two  the  baby  is  entirely  on  artificial  food.    After  it  is 


g6  CARE  OF  INFANTS  AND  CHILDREN 

decided  entirely  to  stop  breast  milk  it  is  usually  better  to  send 
the  mother  away  for  a  week  or  two,  until  the  baby  is  well 
established  on  its  new  regime. 

Constipation. — Constipation  in  breast-fed  infants  is  rarely 
troublesome  if  they  are  started  out  right  and  not  subjected  to 
suppositories,  enemas  and  castor  oil. 

If  the  mother  is  habitually  constipated  an  infant  may  have 
difficulty  also.  The  giving  of  a  teaspoon  of  prune-juice  after 
each  feeding,  with  regularity  as  to  the  time  for  bowel  move- 
ments, will  usually  correct  this  difficulty. 

Pacifier. — The  habit  which  many  children  are  allowed  to 
acquire,  of  sucking  constantly  on  a  nipple,  is  a  vicious  one. 

It  is  usually  begun  in  order  to  keep  babies  from  crying, 
when  in  reality  they  are  suffering  either  from  over-feeding  or 
under-feeding.  After  the  habit  is  acquired  they  cry  when  the 
nipple  is  out  of  their  mouths,  even  when  they  are  otherwise 
perfectly  well.  Sucking  on  a  hollow  nipple  may  result  in  the 
baby's  swallowing  large  quantities  of  air,  thereby  distending  the 
stomach  and  producing  marked  discomfort. 

Irritation  and  Possible  Infection. — The  irritating  effect  upon 
the  mucous  membrane  of  the  mouth  is  frequently  apparent.  The 
roof  of  the  mouth  and  tongue  become  inflamed  as  a  result  of 
the  irritation  from  the  rubber  nipple.  These  nipples  are  always 
dirty,  as  they  are  allowed  to  fall  upon  the  floor,  and  are  put  back 
into  the  mouth  without  being  even  washed.  They  also  offer  a 
favorite  attraction  for  flies,  and  may  be  the  source  of  infectious 
diseases. 

Water  Between  Feedings. — The' common  habit  of  giving 
babies  large  amounts  of  water  between  meals  and  of  allowing 
them  to  go  to  sleep  with  a  bottle  of  water,  is  responsible  for 
many  failures  of  breast  feeding.  It  frequently  happens  that 
babies  who  take  large  amounts  of  water  through  a  nipple  will 
refuse  to  take  the  breast,  probably  because  the  water  in  a  way 
satisfies  their  desire  for  food,  and  also  because  they  can  "  draw  " 
so  much  easier  from  the  artificial  nipple  than  from  the  mother's. 


BREAST  FEEDING 


97 


Premature  Infants 

A  baby  born  of  healthy  parents  after  the  seventh  month  of 
gestation,  if  well  developed  and  having  a  weight  of  over  1500 
grammes  (three  pounds),  may  have  a  fair  chance  for  life  and 
normal  development  if  the  body  temperature 
can  be  maintained  and  if  it  can  have  breast 
milk.  Infants  of  a  less  weight  may  live  and 
develop  normally,  but  their  chances  are  relatively 
smaller. 

Premature  babies  should  not  be  bathed,  but 
should  be  rubbed  with  warm  olive  oil,  and 
rolled  in  warm  cotton  wool,  and  placed  in  an 
incubator.  (No  diaper  should  be  worn.)  The 
temperature  should  be  maintained  at  about  90° 
to  95°  F. 

Breck  Feeder. — If  the  baby  is  too  weak  to 
nurse,  the  milk  should  be  expressed  from  the 
mother's  breasts  and  fed  to  the  baby  through 
a  nipple  or  Breck  feeder  (Figs.  47  and  48). 

Amount  at  Feeding. — The  quantity  of 
milk  which  a  premature  baby  will  take  at  a 
feeding  varies  greatly.  It  is  usually  less  than 
one  ounce.  This  may  be  diluted  at  first  with 
boiled  water  and  later  the  whole  milk  given  as 
it  is  found  that  the  baby  can  tolerate  it.  If 
there  is  no  vomiting,  and  the  stools  are  good,  the 
amount  may  be  increased.  It  is  imperative  that 
the  amount  of  food  be  sufficient  to  maintain  the 
body  weight. 

Time  Between  Feedings. — The  time  be- 
tween feedings  should  be  four  hours  if  the 
quantity  taken  at  a  meal  will  warrant  it.  It  is,  however,  rather 
the  exception  that  this  is  the  case,  and  unless  the  feedings  are  in- 
troduced into  the  stomach  through  a  tube,  the  infant  will  have  to 
be  fed  at  two-  or  three-hour  intervals  for  seven  or  eight  feedings. 


Fig.  47. — Feeder 
for  premature  infant. 
(Rotch.) 


98 


CARE  OF  INFANTS  AND  CHILDREN 


The  caloric  requirements  of  a  premature  baby  are  relatively 
greater  than   for  a  normal  infant. 

Wet  Nurse. — The  establishment  of  the  normal  milk  flow  in 


Fig.  48. — Teterclle  breast-pump,  for  premature  infants.  The  mother  makes  the 
necessary  suction,  and  the  milk  flows  down  the  tube  into  the  baby's  mouth.  Owing  to 
the  tubing,  they  are  difficult  to  keep  clean  and  therefore  are  not  to  be  recommended 
for  general  use. 

these  cases  is  difficult,  because  the  baby  cannot  suck  vigorously 
enough  to  stimulate  secretion.  Tt  is  therefore  usually  necessary 
to  secure  a  wet  nurse,  with  a  normal  baby  of  her  own.  Sufficient 
milk  may  be  pumperl,  or  expressed,  from  her  breasts  for  the  pre- 


BREAST  FEEDING 


99 


mature  baby,  while  her  own  baby  should  be  allowed  to  nurse  the 
other  mother.  This  usually  results  in  a  normal  flow  of  milk 
within  a  few  days.  After  this  the  services  of  the  wet  nurse  may 
usually  be  dispensed  with. 

As  soon  as  the  premature  baby  is  strong  enough  it  should 
be  put  to  the  breast  regularly,  as  it  is  frequently  difficult  to 
maintain  a  proper  flow  of  milk  by  any  other  means. 

Incubator. — The  baby  should  be  taken  from  the  incubator 
only  to  be  changed  and  nursed.  The  room  should  be  above 
80°  F.,  and  the  time  during  which  it  is  kept  out  should  be  as 


Fig.  49. — Improvised  incubator. 

short  as  possible.  When  the  hospital  incubator,  which  is  com- 
plicated and  expensive,  is  not  available,  one  may  be  improvised, 
at  little  expense,  which  will  fill  all  the  requirements  (Fig.  49). 

Improvised  Incubator. — Secure  an  ordinary  box  three  feet 
long  by  two  feet  wide  and  two  feet  deep.  Have  it  properly 
padded  inside.  The  box  should  have  a  sliding  top.  A  false  bot- 
tom made  of  strips  two  inches  wide,  leaving  one-inch  spaces 
between,  should  be  placed  six  inches  from  the  bottom.  This 
space  should  have  a  sliding  door  so  as  to  admit  four  hot  water 
cans.  These  cans  may  be  changed  at  regular  intervals,  one  at  a 
time. 

The  baby  is  placed  on  a  mattress  which  is  raised  a  little  above 


lOO  CARE  OF  INFANTS  AND  CHILDREN 

the  false  bottom,  a  proper  amount  of  space  being  left  between 
the  mattress  and  the  sides  of  the  box  to  allow  the  heat  from  the 
hot  water  cans  to  enter  the  upper  chamber.  A  thermometer 
should  be  placed  on  a  level  with  the  baby  and  the  cover  opened 
sufficiently  for  proper  ventilation. 

For  the  first  days  the  baby  should  be  watched  very  carefully 
and  its  temperature  taken,  until  the  frequency  with  which  the 
hot  water  can  must  be  changed  can  be  accurately  gauged,  so 
that  a  uniform  temperature  can  be  maintained. 

Removal  from  tiii-:  Incubator. — If  the  baby  gains  in  weight 
and  seems  vigorous,  it  may  usually  be  removed  from  the  incu- 
bator after  a  couple  of  months.  Great  care  should  be  taken 
gradually  to  reduce  the  temperature  before  the  baby  is  taken 
out  and  also  not  to  expose  it  to  any  undue  change  for  a  long 
time  after. 

Small  Chance  of  Life  on  Artificial  Food. — Premature 
babies  who  are  fed  upon  artificial  food  have  a  relatively  small 
chance  for  life  and  are  liable  to  be  carried  off  by  even  a  slight 
illness. 

Premature  babies  after  they  become  vigorous  should  be 
subject  to  the  same  rules  for  feeding  as  other  normal  children. 

Premature  babies  should  not  be  on  exhibition,  as  they  are 
particularly  liable  to  pick  up  infections  even  from  persons  who 
are  apparently  well. 

The  Wet  Nurse 

Raising  children  by  means  of  a  wet  nurse  has  always  been  a 
common  custom  among  the  well-to-do  of  many  countries. 

In  this  country,  with  the  exception  of  the  South,  where  the 
colored  mammies  were  utilized  as  wet  nurses  during  slavery  days, 
the  securing  of  proper  wet  nurses  has  always  been  difficult. 

Syi'IIFLIs. — The  difficulty  of  determining  whether  a  woman 
might  not  be  suffering  from  syphilis  has  deterred  many  from 
employing  a  wet  nurse. 

Such  false  doctrines  as  that  of  requiring  the  wet  nurse's 


BREAST  FEEDING  lOl 

baby  to  be  the  same  age  as  the  foster  child  make  a  wet  nurse 
difficult  to  find.  The  best  wet  nurse  is  one  who  is  healthy  and 
who  has  a  normal  baby  of  her  own,  which  she  should  bring 
with  her,  and  continue  to  nurse,  at  least  in  part.  If  a  wet  nurse 
is  required  to  give  up  her  own  baby,  she  will  as  a  rule  be 
unhappy  and  will  not  successfully  nurse  the  other  one. 

Wassermann  Reaction. — Before  engaging  a  wet  nurse, 
she,  as  well  as  her  infant,  should  be  carefully  examined  as  to 
their  physical  condition.  A  Wassermann  reaction  should  always 
be  made  for  syphilis,  and  a  smear  from  the  vagina  should  be 
made  to  determine  the  presence  or  absence  of  gonorrhoea.  Equal 
precautions  should  be  taken  that  a  syphilitic  baby  does  not 
infect  a  healthy  wet  nurse.  Women  of  a  sanguine  temperament 
should  preferably  be  chosen,  as  one  with  a  neurotic  temperament 
rarely  succeeds  as  a  wet  nurse.  A  woman  addicted  to  the  use 
of  alcohol  should,  of  course,  be  rejected.  The  age  of  the  wet 
nurse's  baby,  within  reasonable  limits,  has  little  to  do  with  the 
case  if  the  mother  has  plenty  of  milk. 

Technic. — One  breast  may  be  reserved  for  each  baby,  or, 
if  there  is  not  enough  for  both,  the  foster  baby  may  take  what 
it  requires  and  the  nurse's  baby  be  allowed  to  take  what  remains, 
the  deficiency  being  made  up  with  some  other  food.  It  fre- 
quently happens  that  the  extra  demand  upon  the  breast  results 
in  marked  increase  in  the  amount  of  milk  secreted. 

Diet  of  the  Wet  Nurse. — The  diet  of  the  wet  nurse,  as  of 
all  nursing  women,  should  be  of  plain,  nutritious  food.  Care 
must  be  taken  lest  the  nurse  gorge  herself  with  rich  food,  just 
because  it  is  available.  This  not  infrequently  results  in  the 
baby's  digestion  being  upset  from  a  too  rich  milk  supply. 

Exercise. — The  wet  nurse  should  have  plenty  of  exercise  in 
the  open  air  and  enough  duties  to  perform  to  keep  her  mind 
occupied.  It  should  be  seen  to  that  the  bowels  are  kept  in 
condition,  as  these  women  are  frequently  careless  about  them- 
selves. To  this  end,  plenty  of  coarse  food  should  be  given,  and 
pastry  practically  excluded. 


CHAPTER  XII 
ARTIFICIAL  FEEDING 

■  The  AIilk  Supply. — The  best  available  substitute  for 
mother's  milk  is  clean  cow's  milk.  The  securing  of  an  ideal 
milk  supply  for  infants  is  difficult  and  many  times  impossible. 
It  is  imperative,  however,  that  the  best  available  milk  be  ob- 
tained and  that  we  make  every  effort  in  our  power  by  means 
of  education  and  legislation  to  improve  the  character  of  the 
milk  supply  in  the  community.  Trained  nurses  and  welfare- 
workers,  owing  to  their  peculiar  position  in  the  home  and  the 
community,  are  especially  fitted  to  educate  the  public  concerning 
this  all-important  question. 

The  source  of  the  milk  supply  should  be  carefully  scrutinized. 
The  stable  should  be  modern,  well  aired  and  kept  scrupulously 
clean  (Figs.  50  and  51). 

The  water  supply  should  be  carefully  inspected,  as  wells  are 
frequently  contaminated  with  sewerage. 

The  cows  should  be  properly  brushed  and  kept  clean,  especi- 
ally the  flanks,  udders  and  teats.  The  hands  of  the  milker  should 
be  washed  with  warm  water  and  soap  before  each  milking.  Run- 
ning water  should  be  provided  in  every  stable.  All  utensils  for 
receiving  the  milk  should  be  thoroughly  washed  and  scalded. 
A  particular  modification  of  milk  pail,  which  materially  limits 
the  amount  of  dirt  which  can  fall  into  it  during  the  milking, 
should  be  used  (Fig.  52). 

Milking  Maciiinks. — Milking  machines  (Fig.  53)  if  kept 
scrupulously  clean  make  possible  a  great  advance  in  the  securing 
of  clean  milk.  It  must  be  remembered,  however,  that  milking 
machines  may  be  a  source  of  great  irritation  to  the  udder,  if 
improperly  used,  and  may,  also,  in  case  of  infections  of  the 
udder,  spread  the  disease  from  one  cpw  to  another. 

I02 


ARTIFICIAL  FEEDING 


103 


All  milk  should  be  strained  through  several  thicknesses  of 
sterilized  gauze  directly  after  milking,  then  bottled,  capped,  and 
placed  on  ice  until  delivered. 

jVIilk  from  a  Herd  and  from  One  Cow. — All  things  being 
equal,  the  milk  from  a  herd  is  to  be  preferred  to  the  milk  from 
one  cow,  because  of  its  greater  uniformity.     If,  however,  a 


Fig.  50. — Dirty  barnyards,  wasteful  of  manure  and  increasing  expense  of  keeping  cows 
clean.     (Courtesy  U.  S.  Bureau  Animal  Industry.) 

family  can  have  its  own  cow,  kept  under  ideal  conditions,  the 
milk  is  greatly  to  be  preferred  to  that  procurable  from  the 
average  dairy. 

Di.sE.\si-:  IX  Cows  Affecting,  the  Milk. — The  cows  siiould 
be  healthy  and  carefully  watched  for  any  evidence  of  disease. 
Tuberculosis  is  a  common  disease  among  cattle.  Of  107  .samples 
of  market  milk,  in  New  York  City,  16  per  cent,  contained  tubercle 


104 


CARE  OF  INFANTS  AND  CHILDREN 


Fig.  51. — A  dirty  stable.  (Courtesy  U.  S.  Bureau  of  Animal  Industry.) 


Fig.  52. — Open  and  hooded  milk  pails  A  hooded  pail  will  keep  much  dirt  out  of 
the  milk.  The  hood  can  be  put  on  by  any  competent  tinsmith  for  a  small  price. 
(Courtesy  U.  S.  Bureau  of  Animal  Industry.) 


ARTIFICIAL  FEEDING 


105 


bacilli.  Of  144  samples  of  market  milk  in  Chicago,  10.5  per  cent, 
contained  tubercle  bacilli.  One  tuberculous  cow  may  infect  the 
milk  of  the  whole  herd.  The  bacilli  gain  entrance  to  the  milk 
through  the  udder  or  through  cow  manure,  the  latter  forming 
a  large  part  of  the  sediment  of  market  milk.  All  milch  cows 
should  be  tested  at  least  once  yearly  for  tuberculosis. 


Fig.  53. — A   Model   Dairy,  showing  milking  machine  in  use.     (Broadview  Dairy  Farm. 

St.  Paul,  Minn.) 


Garget. — A  disease  known  as  "  garget  "  frequently  affects 
cows'  udders,  resulting  often  in  abscess  formation  with  large 
amounts  of  pus  given  off  in  the  milk.  Streptococci  are  usually 
found  in  large  numbers  in  the  milk  of  cows  suffering  from 
'  garget."  The  bovine  stre])tococcus  is  not  particularly  malig- 
nant to  human  beings,  but  if  the  human  type  of  streptococcus 
gains  access  to  the  milk,  either  by  an  infection  of  the  udder  with 


Io6  CARE  OF  INFANTS  AND  CHILDREN 

this  organism  or  by  contamination,  it  becomes  extremely  virulent. 
It  was  this  form  of  streptococcus  differentiated  by  Dr.  Theobald 
Smith  and  others  which  caused  the  epidemic  of  malignant  sore 
throat  which  occurred  in  Boston  in  191 1. 

Other  diseases  peculiar  to  cows,  such  as  the  foot-and-mouth 
disease,  may  produce  serious  infections  in  children. 

Gastro-intestinal  disturbances,  due  to  drinking  the  milk  of 
cows  too  soon  after  parturition,  are  common.  Milk  should  not 
be  used  within  15  to  30  days  before,  and  5  days  after,  parturition. 
Such  milk  produces  diarrhoea,  colic,  and  vomiting,  symptoms 
similar  to  those  due  to  mastitis  or  other  febrile  conditions. 

D1SEA.SES  OF  Human  Origin  Stread  Through  Milk.— -The 
frequency  with  which  epidemics  of  contagious  disease  of  human 
origin,  such  as  diphtheria,  scarlet  fever,  typhoid,  dysentery,  and 
malignant  sore  throat,  have  been  traced  to  the  milk  supply,  has 
led  the  health  officials  of  many  large  cities  to  undertake  a  com- 
plete control  of  the  milk  supply.  In  Boston,  from  1907  to  1911, 
inclusive,  there  were  five  epidemics  due  to  milk,  causing  4,096 
definite  cases  of  disease.  This  number  included,  diphtheria,  72 
cases;  scarlet  fever,  1,559  cases;  typhoid  fever,  400  cases,  and 
malignant  sore  throat,  2,065  cases.  This  control  of  the  milk 
supply  has  taken  the  form  of  fixed  standards  as  to  the  cleanliness 
and  general  sanitation  of  the  dairy,  determined  by  inspection, 
the  amount  of  sediment  of  the  milk  and  the  bacterial  count. 

Certified  Milk. — In  New  York,  where  much  of  the  source 
of  the  milk  supply  is  remote,  the  health  authorities  have  under- 
taken the  pasteurization  of  all  milk  except  one  grade — A.  In 
some  places  Milk  Commissions,  ap})ointed  from  the  members  of 
the  local  Medical  Society,  give  a  certificate  to  dairies  producing 
a  particularly  high  grade  of  milk  of  a  low  bacterial  count.  If 
the  milk  maintains  a  bacterial  count  of  less  than  to,ooo  bacteria 
per  cubic  centimetre,  it  may  have  the  stamp  of  the  Commission 
and  may  be  called  certified  milk.  The  value  of  this  certification 
dei)ends  largely  upon  the  efficiency  of  the  Commission. 

The  cleanly  handling  of  milk  is  absolutely  essential  since  it 


Fig.  54. — Ordinary  utensils  necessary  in  the  preparation  and  pasteurization  of  millf. 


Io8  CARE  OF  INFANTS  AND  CHILDREN 

has  been  shown  that  most  milk  epidemics  are  due  to  corltamina- 
tion  from  human  sources. 

That  infected  milk  is  a  large  factor  in  producing  the  in- 
creased mortality  in  infants  during  the  hot  summer  months  has 
been  definitely  established.     Since  the  routine  pasteurization  of 


Fig.  55. — Simple  bottle  rack. 

milk  has  been  practised,  the  mortality  of  infants  in  New  York 
and  other  large  cities  has  been  much  reduced. 

The  technic  of  pasteurizing  the  milk  for  infants  is  a  simple 
one  and  requires  only  elementary  knowledge  and  a  few  proper 
utensils  (Fig.  54). 


ARTIFICIAL  FEEDING 


109 


Care  of  Milk  Bottles. — The  proper  number  of  bottles  for 
the  twenty-four-hour  feedings  should  be  provided.  They  should 
first  be  thoroughly  washed  and  boiled.  The  milk  should  be 
prepared  according  to  the  prescribed  formula  and  the  proper 
amount  poured  in  each  bottle.  Each  bottle  should  then  be  stopped 
with  a  plug  of  sterile  cotton  and  placed  in  a  bottle  rack  ( Fig.  55), 
or  pasteurizer  (Fig.  56).  An  extra  (dummy)  bottle  filled  with 
water  should  contain  a  dairy  thermometer  ( Fig.  54).  The  bottles 
are  then  placed  in  a  water  bath  and  put  on  the  stove  until  the 
temperature  has  reached  150°  F.,  when  the  flame  may  be  lowered, 


Fig.  56. — Freeman  pasteurizer. 

or  turned  out.  They  should  be  allowed  to  remain  at  that  tem- 
perature for  thirty  minutes  and  then  quickly  cooled,  preferably 
by  running  water,  and  then  placed  on  ice  until  needed. 

Before  feeding,  of  course,  the  milk  should  be  heated  to  the 
body  temperature. 

Thermos  Bottles. — The  use  of  thermos  bottles  -to  keep 
milk  warm  for  the  baby  at  night  is  a  dangerous  practice,  as 
germs  develop  rapidly  in  milk  at  body  temperature.  All  milk 
should  be  covered  and  away  from  the  dust  and  flies. 

The  Ice-box. — Milk  when  placed  in  an  ice-box  with  other 
food,  such  as  vegetables,  fruiit,  etc.,  readily  absorbs  the  taste  and 
odor,  which  renders  it  unpalatable,  if  not  unsanitary  (Fig.  57). 


no 


CARE  OF  INFANTS  AND  CHILDREN 


1  ^MM^^^.^I^IIM 

r« 

^" 

^f^m^mxsmL 

-3ti£Ll 

^<i 

i  ^ai^^v^  -- ...^4fc.i 

'1  «.'     -  -Z^^^Ki^g-^t  j^^l^^MM^^B 

■^.^ 

^^^^a^ 

_^ 

( »iiilirii 

^M 

^^^^H^    — —          ^S-«l    kit 

^Ko^  IfmilBi 

■^ 

^^^^^^^^a^B   p-  ^'.^  1^^  ''^  J^rnHfe 

mi 

i 
.  i 

s<fimm^Hp'^^> 

^ 

Fig.    57. — Improper  manner  of  keeping    milk   in    an   ice-box.     (Minnesota  Dairy  and 

Food  Dept.) 

A  separate  small  ice-box  should  be  provided,  if  possible,  for  the 
baby's  milk.    Such  an  one  can  be  made  at  little  expense. 

Procure  an  ordinary  box  eighteen  inches  square  with  a  lid; 


ARTIFICIAL  FEEDING  III 

put  six  inches  of  sawdust  on  the  bottom ;  then  place  a  tin  can 
without  cover  twelve  inches  across  and  twelve  inches  deep  in 
the  centre  of  the  box  so  that  the  upper  edge  is  level  with  the 
upper  edge  of  the  box.  Pack  the  space  around  the  can  with 
sawdust.  Nail  several  thicknesses  of  cardboard  or  paper  to 
the  inside  of  the  lid  and  the  ice-box  is  complete  (Fig.  58). 

The  following  tables  give  the  average  percentage  composi- 
tion of  cow's  milk  and  mother's  milk: 

cow's   MILK 

Proteins 3.0  to    3.5  percent. 

Fats     3-5  to    4.0  per  cent. 

Milk  sugar  4.5  per  cent. 

Salts    0.75  per  cent. 

Water   87.0  to  88.0  per  cent. 

mother's   milk 

Proteins     1.50  to     1.75  per  cent. 

Fats     3.50  to    4.0    per  cent. 

Milk  sugar   6.5     to     7.0    per  cent. 

Salts    0.2  per  cent. 

Water  87.0    to  88.5     per  cent. 

From  a  comparison  of  the  two  tables  it  will  be  seen  that  the 
chief  difference  is  in  the  amounts  of  proteid,  sugar,  and  .salts. 

Digestibility  of  Proteid  and  Fat. — It  was  chiefly  upon 
the  quantity  and  character  of  the  protein  that  the  difficulty  in 
feeding  cow's  milk  to  babies  was  formerly  thought  to  depend. 
This  idea  has  now  been  found  to  be  fallacious  and  we  now 
know  that  the  fat  of  cow's  milk  is  really  more  difficult  of 
digestion  than  the  proteid. 

The  chief  difficulty  with  the  proteid  is  due  to  its  physical 
peculiarity  in  coagulating  in  dense  curds  in  the  stomach,  thus 
rendering  it  difficult  to  pass  the  pylorus.  It  has  been  found 
that  changing  the  character  of  the  curd  by  diluting  with  gruels 
or  by  boiling  overcomes  this  difficulty.     The  caloric  ^  value  of 

*  Calorie — the  amount  of  heat  required  to  raise  the  temperature  of  a 
litre  of  water  one  degree  Centigrade. 


112 


CARE  OF  INFANTS  AND  CHILDREN 


ordinary    cow's    milk    (llolstein)    is    practically    the    same   as 
woman's  milk,  19  to  21  per  ounce,  or  620  to  670  per  quart. 

Breeds  of  Cows. — There  is,  however,  considerable  differ- 
ence in  the  milks  of  different  breeds  of  cows.  The  Jerseys 
(Fig.  59)  and  Guernseys  give  a  milk  containing  as  high  as 
4  per  cent,  proteins,  5.5  per  cent,  of  fats,  and  4.5  to  5  per  cent. 


Pig.  58. — Small  ice-box  for  the  baby's  milk,  which  can  be  made  for  less  than  one  dollar. 

of  sugar,  and  having  a  caloric  value  of  800  to  850  calories  per 
quart. 

In  selecting  a  milk  for  young  infants,  Holstein  (Fig.  60), 
or  ordinary  grade  cows  should  be  preferred  to  the  Jerseys  or 
Guernseys. 

Modification  of  ]\Iilk  for  Infants 

It  has  been  pretty  well  demonstrated  that  the  average  young 

infant  will  not  tolerate  the  same  amount  of  fat  in  cow's  milk  as 

is  normally  in  mother  s  milk,  3.5  to  4  per  cent.    The  proteid  of 

cow's  milk,  which  is  double  in  quantity  that  of  woman's  milk, 


114 


CARE  OF  INFANTS  AND  CHILDREN 


also  frequently  gives  trouble,  in  a  mechanical  way,  unless  diluted 
or  otherwise  changed. 

Pekciintace  Modification  of  Milk. — The  system  of  modi- 
fying milk  which  has  been  in  general  use  in  this  country  until 
recently  was  known  as  the  "  percentage  method."  The  idea 
was  to  make  from  cow's  milk  a  formula  which  approximated 
that  of  mothers'  milk.    To  do  this  at  all  accurately  was  not  an 


Fig.  60. — A  herd  of  Holstein  cows.     (Broadview  Farm,  St.  Paul,  Minn.) 

easy  task,  and  for  the  average  mother  it  usually  resulted  in  the 
giving  of  a  much  larger  percentage  of  cream  than  was  intended. 
It  is  yet  a  common  experience  to  see  infants  getting  the  top  from 
two  quarts  of  milk  in  the  day's  feedings. 

Simple  Dilutions  of  Milk. — A  simple  and  more  uniform 
plan  is  to  use  simple  dilutions  of  milk  and  add  the  necessary 
amount  of  the  other  ingredients  in  the  form  of  sugar,  starch, 
or  fat. 


ARTIFICIAL  FEEDING 


Il6  CARE  OF  INFANTS  AND  CHILDREN 

Since  mother's  milk  and  cow's  milk  have  the  same  food 
value,  670  per  quart,  it  is  apparent  that  if  we  dilute  cow's  milk 
with  an  equal  quantity  of  water,  the  same  quantity  will  have 
only  one-half  of  the  original  food  value. 

The  simple  dilutions  of  ^,  ^,  %  whole  milk  will  usually  be 
found  to  be  tolerated  at  the  proper  ages.  The  necessary  amount 
of  sugar  may  usually  be  added  to  bring  the  sugar  content  up 
to  6  or  7  per  cent. 

For  the  preparation  and  use  of  the  different  milk  mixtures 
used  in  artificial  feeding  the  following  list  of  utensils  will  be 
found  necessary : 

Two-quart  porcelain  pitcher. 

Pint  or  quart  graduate. 

Glass  funnel  for  filling  the  bottles. 

Dairy  thermometer. 

Nursing  bottles,  the  proper  number  for  the  day's  feedings. 
(The  bottles  may  be  purchased  by  the  dozen  very  cheaply.) 

Rack  for  bottles. 

Bottle  cleaner. 

Large  pan  for  water  bottle,  or  double  boiler. 

Gas  stove. 

Roll  of  sterilized  absorbent  cotton. 

Nursing  Bottles  and  Nipples 

A  simple  cylindrical  bottle  with  a  large  mouth,  with  a  scale 
of  ounces  on  the  side,  is  the  most  practical,  all  things  being  taken 
into  consideration.  The  shoulder  is  such  that  it  can  be  readily 
cleaned ;  it  is  cheap,  and  of  such  size  that  the  aggregate  number, 
for  the  day's  feedings,  occupy  a  minimum  of  space  in  the  ice- 
box. The  small  grooves  in  the  neck  of  the  bottle  make  the 
nipple  non-collapsible. 

Bottles  such  as  Nos.  4,  5,  6.  and  7  in  Fig.  62,  with  glass  or 
rubber  tubes,  are  absolutely  unsanitary.  They  are  prohibited 
by  law  in  some  States,  and  should  be  in  all. 


ARTIFICIAL  FEEDING 


117 


Nipples  should  be  of  the  simple  variety,  preferably  of  dark 
rubber,  and  with  openings  as  small  as  possible.  Blind  nipples 
may  be  purchased  and  the  openings  made  the  size  desired  by 
means  of  a  red-hot  needle.  The  size  of  the  opening  should  be 
large  enough  to  permit  the  milk  to  drop  fast  when  the  bottle  is 
inverted,  but  not  large  enough  to  permit  it  to  run  in  a  stream. 

Nipples  should  rarely  be  boiled,  as  boiling  destroys  the  rub- 
ber. They  should  be  thoroughly  washed  after  each  nursing, 
with  soap  and  running  water,  and  should  be  turned  inside  out 


Fig.  62. — Nursing  bottles  and  nipples.  No.  lis  simple  and  having  no  shoulder  is  easier 
to  clean  than  No.  2.  No.  3  is  easily  cleaned  but  the  nipples  arc  hard  and  they  are  more 
expensive  than  Nos.  1  and  2.  No.  4,  5,  6,  and  7,  are  absolutely  bad  and  should  never 
be  used. 


so  that  they  are  thoroughly  clean.  They  should  be  kept  clean 
and  dry  in  a  covered  sterilized  dish  until  needed. 

Bottles  should  be  filled  with  cold  water  at  once  after  feed- 
ings, to  prevent  the  milk  from  drying  in  them  and  rendering  its 
removal  difficult. 

A  matter  of  much  more  vital  importance  than  the  exact 
percentages  is  the  proper  amount  of  food  for  the  baby's  growth 
and  development  and  one  that  it  can  digest  and  assimilate. 

The  following  formulae  made  from  simple  dilutions  of  milk 
will  usually  be  tolerated  by  norrnal  infants  at  different  ages. 


it8 


CARE  OF  INFANTS  AND  CHILDREN 


Akc 

Week: 
I   

2 

3 

Month : 
I   

2 

3 

4 

6 

8 

lo 

12 


No.  of 
feed- 
ings 


Oz.at 
feeding 


Oz. 

milk 


2 

3 

A'A 

5 

6 

7 


1-3 

3-5 
5-7 

7-9 
13 
15 

i8 

23 

28 

30 
30 


Oz. 

sugar 


Oz.  oat- 
meal or 
barley- 
water 


Oz. 

water 


Oz. 
total 


8-  6 

9 

9-  7 

12 

1 3-1 1 

18 

II-  9 

18 

14 

27 

15 

30 

12 

30 

12 

35 

14 

40 

10 

40 

10 

40 

Ca- 
lories 

per 
pound 


13 
25 
29 

40 
50 
44 
50 
45 
45 
40 
40 


The  foregoing  formulae  are  designed  to  serve  as  a  guide,  it 
being  understood  that  many  robust  children  will  require  more 
food  than  is  prescribed  for  their  ages. 

It  is  a  good  rule  to  follow,  to  give  the  baby  the  least  amount 
of  food  upon  which  it  gains  a  proper  amount  weekly  in  weight 
and  is  otherwise  well  nourished. 

The  barley  or  oatmeal  water  is  made  by  putting  two  table- 
spoons of  the  flour  in  one  quart  of  water  and  boiling  for  one- 
half  hour  and  straining  through  a  fine  sieve. 

The  sugar  us^d  may  be  either  milk,  cane  or  malt  sugar,  the 
cane  sugar  having  the  advantage  over  the  other  two  of  being 
cheaper. 

The  malt  sugar  has  a  slightly  higher  food  value  than  the 
others,  as  it  is  absorbed  without  being  changed.  It  is  also  more 
laxative  than  other  fomis.  There  is  considerable  difference  in 
the  bulk  of  the  different  sugars  and  flours,  as  will  be  seen  in 
the  following: 


ARTIFICIAL  FEEDING  II9 

By  weight  By  measure 

I  ounce  cane  sugar  =1^  ounces 

I  ounce  Dextro  Maltose  ^^  i^  ounces 

I  ounce  milk  sugar  =  1J/2  ounces 

I  ounce  browned  wheat  flower  =2J4  ounces 

I  ounce  barley  flour  ^^2%  ounces 

I  ounce  oatmeal  =3      ounces 

I  ounce  malted  milk  ^  2      ounces 

For  caloric  values  of  different  food  elements  see  page  128. 

Mixed  Feeding. 

Babies  who  are  artificially  fed  should  begin  to  have  some 
extra  food  after  they  are  six  months  old,  and  if  the  food  is 
sterilized  they  should  begin  having  a  little  orange  juice  well 
diluted  or  other  uncooked  fruit  juice  as  early  as  the  second  or 
third  month,  or  even  from  the  beginning. 

The  same  rules  for  the  mixed  feeding  of  bottle  babies  may 
be  applied  as  already  has  been  described  in  the  case  of  those  fed 
on  the  breast. 

The  Stools  in  Artieici ally-fed  Babies 

The  stools  of  babies  fed  on  cow's  milk  have  quite  a  different 
appearance  than  those  fed  upon  the  breast,  and  there  are,  in 
fact,  other  very  essential  differences  in  the  character  of  the  two. 

The  Color. — The  color  of  the  stools  from  cow's  milk  is  a 
pale  yellow  and  smoother  and  of  a  firmer  consistency  than 
breast  milk  stools.  The  color,  however,  is  much  modified  by 
the  .addition  of  the  different  gruels  and  sugars.  Malt  sugar,  for 
example,  gives  the  stools  a  brownish  tinge,  as  also  does  the 
addition  of  barley  gruel,  particularly  if  made  from  pearl  barley. 

The  Odor. — The  odor  of  the  stools  is  also  quite  different 
from  those  of  infants  fed  on  breast  milk.  This  is  probably 
due  to  the  difference  in  the  character  of  the  bacteria  and  to  the 
larger  amount  of  fatty  acids  present. 

Reaction. — The  normal  breast  milk  stool  is  slightly  acid  in 
reaction,  that  of  the  artificially-fed  being  slightly  alkaline. 


I20  CARE  OF  INFANTS  AND  CHILDREN 

Number  During  the  Day. — There  should  be  at  least  one 
good  movement  of  the  bowels  daily,  and  preferably  two. 

There  is  a  marked  tendency  to  constipation  in  babies  fed  on 
cow's  milk. 

'Normal  stools  are  smooth  and  of  a  salve-like  consistency. 

Fat  Stools. — Stools  which  are  hard,  brittle,  and  pale  in 
color,  with  a  foul  odor,  indicate  the  presence  of  an  abnormal 
amount  of  fat  in  the  form  of  soap.  Such  a  condition  demands 
a  radical  change  in  food,  usually  a  reduction  or  elimination  of 
the  fat  and  the  substitution  of  a  sufficient  amount  of  carbo- 
hydrates to  compensate  for  the  caloric  loss.  The  small  white 
curds  mixed  in  with  green  is  another  form  of  fatty  soap  stool. 

The  loose  acid  stool,  which  burns  the  skin  about  the  but- 
tocks, usually  points  to  an  excess  of  sugar  or  other  carbohydrate 
in  the  food. 

The  large  curds  the  size  of  a  pea,  or  bean,  mixed  in  with  a 
stool  are  usually  made  up  of  masses  of  undigested  casein  with 
which  is  often  incorporated  considerable  fat.  They  do  not 
appear  in  the  stool  if  the  milk  has  been  boiled. 

Green  Stools. — Green  stools,  if  persistent,  in  artificially-fed 
babies,  always  mean  an  excess  of  some  element  in  the  food.  It 
should  be  regarded  as  serious  and  the  physician's  attention  should 
always  be  called  to  the  condition. 

Black  Stools  Indicating  Blood. — Black,  tarry  stools,  re- 
curring in  infants  after  the  first  week  when  the  meconium  has 
passed,  indicate  the  presence  of  blood,  unless  iron  or  bismuth  is 
being  given. 

Stool  Analysis. — A  specimen  of  the  stool  should  always  be 
retained  for  examination  by  the  physician.  An  analysis  of  the 
stool  is  frequently  the  only  means  by  which  a  diagnosis  can  be 
arrived  at,  or  the  errors  in  the  diet  corrected.  Consitipation  in 
artificially-fed  babies  is  frequently  a  serious  problem  and  re- 
quires a  careful  study  of  the  individual  case. 

If  the  stools  are  well  digested  and  of  a  proper  consistency, 
the  question  of  voluntary  evacuation  can  always  be  met  suc- 
cessfully by  regular  habits,  and  the  elimination  of  cathartics, 


ARTIFICIAL  FEEDING 


121 


injections,  and  glycerine  suppositories.  Under  the  conditions 
mentioned,  when  the  stools  are  of  normal  consistency,  the  bowel 
will  empty  itself  if  left  alone.  A  soap  stick  may  sometimes  be 
resorted  to,  to  produce  the  necessary  effort  on  the  part  of  the 
baby.  This  should  always  be  done  at  the  same  time  and  the 
baby  held  in  the  proper  position  so  that  it  can  use  its  muscles 
to  the  best  advantage.  At  six  months  a  baby  may  be  put  regu- 
larly on  the  chair,  being,  of  course,  prop- 
erly sup}X)rted.  It  will  soon  learn  to  know 
the  significance  of  this  and  will  then  empty 
the  bowel  only  at  these  times.  The  back 
should  be  supported  in  the  upright  position 
by  the  nurse  and  the  child  never  allowed 
to  sit  alone  until  it  can  raise  and  support 
itself. 

When  the  stools  are  hard,  so  that  great 
masses  are  packed  in  the  rectum,  the  food 
will  have  to  be  modified. 

The  hard  condition  of  the  stools  may 
sometimes  be  overcome  by  substituting 
oatmeal  for  barley  gruel  and  giving  Dextro 
Maltose  instead  of  milk  sugar  or  cane 
sugar. 

Microscopic  Examination.  —  The 
hard,  chalky  stools  are  frequently  due  to 
an  excess  of  fatty  soaps.  By  adding  a 
drop  of  glacial  acetic  acid  to  a  little  of  the 
stool  and  mixing  it  thoroughly  on  a  glass  slide,  it  will  frequently 
be  found  that  these  stools  are  made  up  largely  of  fat  which  may 
be  seen  under  the  microscope  in  the  fomi  of  feathery  crystals. 

This  condition  of  the  stools  is  usually  accompanied  by  a 
strongly  ammoniacal  urine,  which  will  be  readily  noted  whenever 
the  diaper  is  changed. 

Under  such  conditions  the  fat  must  be  largely  removed  from 
the  milk  (Fig.  63)  and  Dextro  Maltose  and  starch  added  as  a 
substitute  to  increase  the  caloric  value  of  the  food. 


Fig. 


63. —  Milk  bottle  and 
cream  dipper. 


122  CARE  OF  INFANTS  AND  CHILDREN 

Fruit  Juices  for  Constipation. — After  a  baby  is  five  or 
six  months  old  it  may  have  some  fruit  juice,  such  as  orange 
juice  or  prune  juice,  or  even  the  prune  pulp  which  has  beeil 
put  through  a  sieve.  Babies  who  are  habitually  constipated 
should  have  a  mixed  diet  as  early  as  possible  and  the  milk 
materially  reduced. 

Proper  Use  of  Enemas  and  Mild  Laxatives. — Occasion- 
ally mild  laxatives,  such  as  milk  of  magnesia,  or  an  enema,  may 
be  used  as  a  temporary  measure,  always  keeping  in  mind  the 
fact  that  such  things  are  simply  palliative  and  should  be  gradu- 
ally discontinued. 

If  a  baby  is  thriving  properly,  the  fact  that  it  is  somewhat 
constipated  should  not  be  taken  too  seriously,  and  must  simply 
be  considered  as  one  of  the  unfortunate  features  of  artificial 
feeding. 

Over-feeding. 

Many  of  the  digestive  disturbances  from  which  infants  suffer 
are  due  to  over- feeding.  There  is  a  great  tendency  on  the  part 
of  people  generally  to  over-feed  their  children. 

There  is  always  a  certain  rivalry  among  mothers  to  see  who 
can  produce  the  fattest  baby.  They  should  be  taught  that  a 
normal  gain  in  weight  is  what  is  to  be  sought  and  that  the  fat 
babies  are  often  rhachitic,  and  that  babies  who  are  over-fed, 
even  if  apparently  well,  are  almost  sure  to  have  serious  digestive 
disturbances   during  the  hot  weather. 

It  is  not  infrequent  that  children  who  are  over-fed  suddenly 
cease  to  gain  in  weight  and  begin  to  lose  steadily.  If  the  over- 
feeding is  persisted  in  they  gradually  develop  a  condition  of 
intoxication  and  intolerance  for  food.  Many  of  the  severe  cases 
of  atrophy  or  marasmus  have  their  beginning  in  over- feeding. 

It  frequently  happens  where  infants  have  been  over-fed  and 
have  ceased  to  gain  in  weight,  that  a  proper  gain  is  re-established 
as  soon  as  the  amount  of  food  has  been  properly  reduced 
(paradoxical  gain  in  weight). 


ARTIFICIAL  FEEDING  123 

It  is  in  this  connection  that  a  knowledge  of  caloric  values 
•   becomes  of  great  value  (page  128). 

Infants  who  have  been  greatly  over-fed  with  some  particu- 
lar element  of  the  food,  for  example  with  fat  or  sugar,  are 
almost  always  intolerant  to  that  element  for  a  considerable  time) 
so  that  it  will  usually  be  necessary  to  eliminate  it  to  a  large 
extent  from  the  diet. 

For  example,  if  a  baby  has  been  fed  on  food  rich  in  fat,  and 
developed  a  severe  gastro-intestinal  disturbance  as  a  result,  the 
logical  food  for  some  weeks  would  be  one  with  a  low  fat  con- 
tent, such  as  buttermilk  or  malt  soup  (page  132).  If,  on  the 
other  hand,  it  had  been  fed  on  one  of  the  patent  foods  with  a 
high  sugar  content,  the  logical  food  would  be  a  simple  dilution 
of  milk  and  water  without  the  addition  of  any  sugar. 

The  results  of  over-feeding  are  so  many,  and  the  conditions 
so  complicated,  that  only  the  most  careful  analysis  will  some- 
times discover  the  way  to  a  proper  recovery. 

COLIC 

Colic  in  artificially- fed  infants,  as  well  as  those  fed  on  the 
breast,  is  usually  due  to  over-feeding.  In  bottle-fed  infants  the 
indigestion  is  liable  to  be  due  to  some  particular  element  in  the 
food.  This  can  usually  be  determined  by  a  proper  analysis  of 
the  stools. 

If  the  stools  are  bad  in  character,  loose,  green,  or  curdy,  it 
is  probable  that  the  crying  is  due  to  indigestion  (colic).  If  the 
stools  are  good  and  there  is  no  vomiting,  and  the  baby  is  gaining 
in  weight,  the  crying  is  due,  in  all  probability,  to. its  being  spoiled. 

Ga.s  on  the  Stomach. — The  constant  solicitude  of  nurses 
because  the  baby  has  "  gas  on  the  stomach  "  is  unwarranted. 
All  bottle-fed  babies  have  gas  in  the  stomach.  They  swallow  it 
with  their  meals  in  the  form  of  air.  If  the  baby  is  gently  raised 
in  the  sitting  posture  the  gas  will  usually  **  come  up."  This  may 
be  done  in  the  middle  of  a  feeding  if  the  stomach  seems  unusually 
distended. 


124  CARE  OF  INFANTS  AND  CHILDREN 

Carrying  infants  because  they  have  coHc  should  never  be 
allowed.  If  they  really  have  colic,  the  cause  of  the  colic  should 
be  removed.  Babies  who  are  carried  and  rocked  will  cry  when 
they  have  colic,  and  also  when  they  are  well.  Occasionally 
severe  attacks  of  colic  may  be  relieved  by  an  enema. 

Babies  should  be  fed  while  they  are  lying  on  their  beds,  the 
upper  part  of  the  body  being  somewhat  elevated  by  means  of  a 
properly  graduated  hair  pillow.  The  baby  should  be  turned 
slightly  on  the  right  side,  as  it  has  been  found  that  the  stomach 
empties  itself  sooner  in  that  position. 

The  bottle  should  always  be  held  by  the  nurse,  or  attendant, 
until  it  is  empty  (Figs.  64  and  65).  From  fifteen  to  twenty 
minutes  should  be  occupied  with  the  meal. 

Vomiting 

Regurgitation  of  Food  from  Pressure  and  Position. — 
Owing  to  the  relaxed  condition  of  the  cardiac  opening  of  the 
stomach,  regurgitation  of  food  occurs  very  easily  in  infants.  If 
pressure  is  made  over  the  stomach  of  an  infant  after  a  meal  it 
will  regurgitate  some  of  the  food,  or  if  its  head  is  lower  than  its 
heels,  some  of  the  milk  will  run  out  of  the  stomach,  as  it  would 
from  an  inverted  bottle  without  a  cork.  Real  vomiting,  produced 
by  a  spasm  of  the  stomach  and  co-ordinate  fixation  of  the 
diaphragm  by  which  the  food  comes  out  with  a  gush,  is  usually 
due  ito  a  disordered  condition  of  the  stomach  from  over-feeding 
or  to  pylorospasm.  The  over-feeding  with  fat  is  a  common 
source  of  vomiting  under  these  conditions.  The  vomitus  is 
usually  very  sour  and  has  the  odor  of  fatty  acids. 

If  babies  vomit  food  up  to  the  time  for  the  next  meal,  the 
stomach  should  be  given  a  rest  for  several  meals,  and  boiled 
water,  or  barley  water,  given.  The  milk  should  be  reduced, 
particularly  the  fat,  and  the  intervals  between  feedings  increased 
to  four  hours,  with  not  to  exceed  five  feedings  in  twenty-four 
hours. 

Pylorospasm. — If  the  vomiting  continues,  and  particularly 


Fig.  64.— The  bottle  should  be  held  by  the  nurse  or  attendant  until  it  is  empty     (The  right  way.) 


c 


\ 


Flc.   05.  —The  wrong  way  of  feeding  the  baby. 


126  CARE  OF  INFANTS  AND  CHILDREN 

if  it  is  projectile  in  character,  sometimes  coming  through  the 
nose  with  force,  a  pylorospasm  must  be  thought  of,  and  the 
physician's  attention  called  to  the  condition.  These  cases  lose 
weight  rapidly,  as  practically  no  food  passes  the  small  end  of 
the  stomach.  After  a  meal,  stomach  waves  can  usually  be  seen 
extending  from  left  to  right.  Usually  several  of  these  waves 
are  to  be  seen  at  the  same  time,  one  following  the  other. 

Pyloric  Stenosis. — In  some  of  the  persistent  cases  a  steno- 
sis, or  obstruction,  in  the  form  of  a  small  tumor,  varying  in  size 
from  a  filbert  to  a  hickory-nut,  is  found  at  the  pylorus. 

The  treatment  in  these  cases  will  dififer  much  under  different 
circumstances.  Many  of  them  occur  in  breast-fed  babies.  The 
intervals  between  feedings  should  be  as  long  as  possible — ^4-5 
hours.  It  is  frequently  necessary  to  pump  the  milk  from  the 
breasts,  remove  the  cream  and  give  it  diluted  with  water  or 
barley  water,  or,  if  fed  on  cow'e  milk,  the  cream  should  be 
removed  and  the  mixture  made  with  skimmed  milk. 

Irrigation  of  the  stomach  at  least  once  daily  is  often  of  great 
benefit. 

Hess,  of  New  York,  has  resorted  to  feeding  these  cases  by 
means  of  a  catheter,  passing  it  through  the  pylorus  and  intro- 
ducing the  food  directly  into  the  duodenum.  These  cases  should 
be  kept  very  quiet  and  absolutely  free  from  excitement,  as 
there  is  a  large  nervous  element  to  be  considered.  Careful 
weighings  should  be  made  daily.  If,  in  spite  of  everything,  the 
baby  still  vomits  much,  and  is  losing  steadily  in  weight,  an 
operation  by  a  skilled  surgeon  will  become  imperative.  Too 
many  of  these  cases  are  allowed  to  go  until  they  are  in  extremis 
before  operation  is  resorted  to,  and  then  usually  without  result. 

RECURRENT  VOMITING CYCLIC  VOMITING 

(Intermittent  V^omiting) 
Certain  children  after  two  years  of  age,  particularly  those 
of  a  neurotic  tem[>erament,  have  periodic  attacks  of  vomiting 
which  frequently  have  no  apparent  bearing  on  the  condition  of 
the  stomach  or  on  the  character  of  the  food  taken. 


ARTIFICIAL  FEEDING  127 

There  is  no  doubt  that  attacks  are  frequently  precipitated  by 
indiscretion  in  food,  but  they  frequently  occur  when  they  can- 
not be  accounted  for.  The  attacks  are  usually  preceded  by  a 
few  hours  of  lassitude ;  the  tongue  may  or  may  not  be  coated. 

AcKTONE  IN  THE  Urine  AND  Breath. — The  breath  usually 
has  a  sweetish  odor  due  to  acetone  and  the  urine  contains  acetone 
in  an  abnormal  amount.  I  am  aware  that  some  authorities,  chiefly 
European,  claim  that  the  acetone  is  simply  a  result  of  'starvation. 
I  have,  however,  seen  it  present  from  the  beginning  and  when 
there  was  no  starvation  period.  The  vomiting  may  persist  at 
intervals  for  several  days,  the  child  being  unable  to  retain  even 
small  amounts  of  water. 

Under  such  conditions  water  should  be  furnished  by  rectal 
injections  of  normal  salt,  introduced  slowly,  or  by  the  drop 
method.  It  is  not  uncommon  that  after  the  vomiting  has  con- 
tinued for  several  hours,  the  vomitus,  which  is  usually  mucus 
and  bile,  may  contain  some  blood.  Under  such  conditions  no 
food  should  be  given  by  the  mouth  until  the  vomiting  has  ceased. 
After  the  attack  is  over  these  children  will  gorge  themselves  if 
allowed  to.  They  should  not  be  starved,  but  allowed  to  return 
gradually  to  a  plain  prescribed  diet.  A  careful  regulation  of 
the  diet,  sometimes  with  the  elimination  of  milk  and  eggs,  is 
effective  in  lessening  the  attacks.  The  condition  is  not  unlike 
what  is  known  as  "  sick  headache  "  in  adults,  and  there  may  be  a 
history  of  migraine  in  the  parents. 

The  Caloric  Values  of  Milk  Mixtures  and  Their  Applica- 
tion TO  Feeding 

The  caloric  values  of  the  different  food  elements  have  been 
carefully  worked  out  by  Rubner  and  Huebner,  so  that  all  that 
is  necessary  to  determine  the  total  value  of  any  mixture  is  to 
know  the  amounts  of  each  ingredient' in  ounces  or  grammes  and 
apply  the  prescribed  value. 

The  following  are  the  approximate  caloric  values  for  the  fol- 
lounng  articles  of  diet  zvhich  go  to  make  up  the  usual  milk 
mixtures: 


128  CARE  OF  INFANTS  AND  CHILDREN 

Food  Caloric  value  per  ounce 

Whole  milk  (3^^-4  per  cent.  faO   23 

Skimmed  milk  (J^  per  cent,  fat)   13 

Buttermilk   (^  per  cent,  fat)    13 

Gravity  cream  (16  per  cent,  fat)    56 

Sugar  (by  measure)    80 ;  by  weight,  120 

Flour,  wheat,  or  barley  (measure)  55 ;  by  weight,  120 

Oatmeal   (measure)    40 ;  by  weight,  120 

Suppose  we  have  a  milk  mixture  of  30  ounces,  this  being 
the  total  food  in  twenty-four  hours. 

The  mixture  is  made  up  of  ^  milk  and  Ys  barley  gruel  and 
I  ounce  sugar  (by  measure). 

The  milk  contained  in  the  mixture  would  therefore  be  ^  of 
30,  or  20  ounces. 

The  oatmeal  gruel  in  the  mixture  would  be  10  ounces. 

And  I  ounce  of  sugar. 

The  milk  has  a  caloric  value  of  23  per  ounce;  therefore,  the 
value  of  the  milk  is  20  times  23,  or  460  calories. 

The  I  ounce  of  sugar,  by  measure,  has  a  value  of  80  calories. 
How  shall  we  determine  the  value  of  the  gruel? 

We  find  on  inquiry,  the  pint  of  gruel  contained  ^  ounce,  by 
measure,  of  barley  flour,  and  that  the  pint  was  allowed  to  boil 
down  to  10  ounces.  The  gruel  then  contains  all  the  barley,  and 
has  a  caloric  value  of  2yy2,  i.e.,  Yz  of  55. 

The  total  caloric  value  of  the  mixture  is  therefore  : 

20      ounces  whole  milk 460  calories. 

^  ounce  flour  (by  measure)   27  calories. 

I       ounce  sugar  (by  measure)   80  calories. 

Total    567  calories. 

If  the  weight  of  the  baby  is  16  pounds,  and  its  needs  accord- 
ing to  rule  are  50  calories  per  pound,  its  total  needs  are  800 
calories. 

It  is  getting  567  calories,  therefore,  according  to  Huebner,  it 
is  under- fed  by  the  difference  between  800  and  567,  or  by  233 
calories. 


ARTIFICIAL  FEEDING  129 

If  in  addition  to  tlie  above  formula  the  mixture  contains  i 
ounce  of  ordinary  cream,  skimmed  from  the  top  of  the  bottle, 
the  value  of  the  food  would  be  increased  by  56  calories.  The 
mixture  would  now  have  a  value  of  567  plus  56  or  623  calories. 
There  still  being  a  deficiency  of  food  this  would  have  to  be 
made  up  by  a  still  further  increase  of  some  or  all  of  the  in- 
gredients as  indicated  by  the  tolerance. 

Special  Preparations  of  Milk  and  the  Indications  for 
Their  Use 

Under  certain  conditions  it  will  be  found  necessary  to  use 
special  preparations  of  milk  other  than  the  regular  milk  mixtures, 
which  contain  all  of  the  elements  of  the  milk. 

For  example,  there  are  children  who  under  certain  conditions 
are  unable  to  tolerate  the  fat  of  cow's  milk.  Such  an  intoler- 
ance may  be  manifested  by  vomiting,  or  by  diarrhoea  with  green 
curdy  stools,  or  the  stools  may  be  hard,  dry,  and  chalky,  with 
the  ammoniacal  urine  already  described. 

Skimmed  Milk.^^— It  will  be  necessary  in  such  cases,  there- 
fore, to  give  a  food  low  in  fat,  or  sometimes  fat  free.  Cow's 
milk  which  has  been  allowed  to  stand  for  five  or  six  hours  and 
then  carefully  skimmed  still  contains  about  0.5  per  cent,  of  fat. 

Separated  Milk. — Milk  which  has  been  put  through  a  prop- 
erly adjusted  separator  may  be  practically  fat  free. 

Ordinary  buttermilk  (the  by-product  from  the  making  of 
butter)- has  a  fat  content  of  about  0.5  per  cent. 

Percentage  of  Fat  in  Gruels. — Most  of  the  cereal  gruels, 
such  as  oatmeal,  barley,  rice,  wheat,  flour,  arrowroot,  are  for  all 
practical  purposes  fat  free.  However,  they  contain  such  a  small 
amount  of  proteid  and  such  a  large  percentage  of  starch  that 
they  cannot  be  utilized  alone  for  any  great  length  of  time. 

buttermilk 
As  a  diet  for  infants  where  little  fat  is  required,  buttermilk 
has  enjoyed  a  reputation  among  Europeans  for  many  centuries. 
Buttermilk  is  made  by  souring  milk  or  cream  by  means  of 

9 


I30  CARE  OF  INFANTS  AND  CHILDREN 

lactic  acid  bacilli,  after  which  the  butter  fat  is  removed  by  churn- 
ing. When  fresh  buttermilk  cannot  be  procured  from  the  dairies 
it  can  readily  be  made  at  home  by  churning  soured  cream  in  a 
small  glass  churn,  which  can  be  purchased  at  any  department 
store. 

The  percentage  composition  of  buttermilk  is  as  follows : 

Proteid    2  to  3       per  cent. 

Fat    ^  to  I       per  cent. 

Sugar     3  to  314  per  cent. 

Its  acidity  is  about  0.5 

Caloric  value,  1 1  per  ounce,  or  350  per  quart. 

In  the  process  of  souring,  the  calcium  casein  is  converted  into 
lacto-casein.  The  sugar,  by  the  process  of  fermentation,  is  re- 
duced to  about  three  and  one-half  per  cent.  In  order  to  in- 
crease the  caloric  value  of  buttermilk  it  is  usually  prepared  by 
adding  a  certain  amount  of  sugar  and  flour.  The  mixture  is  then 
brought  to  a  boil. 

The  following  is  the  author's  modification  of  Baginsky's 
formula :  ^ 

Buttermilk     i  quart. 

Wheat   flour    (l)rowned)    .  .    i  to  2  tablespoons. 
Sugar    (cane) 2  to  4  tablespoons. 

The  flour  is  first  mixed  thoroughly  in  a  cup  with  a  little 
buttermilk  and  then  added  to  the  buttermilk.  It  is  then. put  on 
the  fire  and  brought  slowly  to  the  boil,  stirring  constantly  in 
order  to  prevent  it  from  curdling. 

After  it  has  boiled  three  minutes  the  sugar  is  added  and  the 
mixture  again  brought  to  the  boil.  It  is  then  removed  and 
cooled  rapidly  and  kept  on  ice  until  needed. 

This  preparation  has  a  caloric  value  of  from  500  to  650  per 
quart,  depending  on  the  amount  of  sugar  and  starch  added. 

After  the  preparation  has  stood  for  a  couple  of  hours  the 

^ "  Buttermilk  as  an  Infant  Food,"  Ramsey,  Walter  R.,  St.  Paul  Medi- 
cal Journal,  January,  1904. 


ARTIFICIAL  FEEDING  131 

starch  settles  to  the  bottom  and  carries  with  it  the  casein,  which 
has  been  divided  into  fine  particles. 

The  buttermilk  formula  may  be  given  in  the  same  amounts 
as  other  milk  mixtures.  In  young  infants  it  may  be  diluted  with 
water  as  required  for  the  individual  case.  Other  preparations  of 
sour  milk  are  in  quite  general  use.  They  are  made  by  souring 
whole  milk  by  means  of  lactic  acid  bacilli,  or  the  bacillus  bul- 
garicus.  If  fat-free  milk  is  desired  skimmed  milk  may  be  sub- 
stituted for  whole  milk. 

Buttermilk  and  sour  milks,  such  as  matzoon,  kephyr,  or 
koumiss,  made  from  the  milk  of  the  cow,  goat,  mare,  or  ass, 
are  perfectly  wholesome  foods  not  only  for  sick  children,  but 
for  healthy  ones  as  well.  All  children  should  be  taught  to  like 
buttermilk  and  should  have  it  at  intervals  during  their  whole 
lifetime.  According  to  some  authorities,  the  good  age  to  which 
many  of  the  people  in  the  Eastern  countries  (Bulgaria)  attain, 
is  primarily  due  to  their  constant  use  of  sour  milk. 

WHEY  PREPARATIONS 

Whey  is  made  by  curdling  whole  milk,  or  skimmed  milk,  with 
junket  tablets,  or  other  preparations  of  rennet,  such  as  Fair- 
child's  essence  of  pepsin. 

The  prescribed  number  of  tablets,  or  essence  of  pepsin,  is 
added  to  a  quart  of  milk  and  the  temperature  maintained  at 
about  100°  F.  until  the  milk  is  curdled.  The  liquid  portion  of 
the  milk  (whey)  is  then  removed  by  straining  it  through  a 
cheese  cloth,  or  fine  sieve  under  pressure.  One  quart  of  milk 
will  yield  about  twenty  ounces  of  whey. 

The  percentage  analysis  of  whey  is  approximately  as  follows  : 

Protein     0.75  to  i.o    per  cent. 

Fat    o.oi  to  0.25  per  cent. 

Sugar    4.       to  4.50  per  cent. 

Salts    0.4    to  0.6    per  cent. 

Owing  to  the  fact  that  whey  is  practically  fat  free,  it  may  be 
modified  as  required  for  the  individual  case,  sugar  or  starch 
being  added  as  indicated. 


132  CARE  OF  INFANTS  AND  CHILDREN 

Keller's  malt,  soup 

This  preparation  was  designed  by  Keller  particularly  for  the 
cases  which  he  termed  "  Fettnahrschaden,"  a  condition  result- 
ing from  intolerance  to  the  fat  of  cow's  milk.  It  is  not  fat  free, 
but  contains  much  less  fat,  i  per  cent.,  than  the  average  milk 
mixtures,  but  a  large  percentage  of  carbohydrate. 

Malt  soup  is  made  in  the  following  manner : 

Whole  milk  1 1  ounces. 

Cold  water  20  ounces. 

Wheat   flour    lYz  ounces. 

Malt  soup  extract   3  ounces. 

Mix  flour  and  water  together  and  bring  to  a  boil.  Next  add 
the  malt  extract  and  bring  to  a  boil.  Lastly  add  the  milk,  stirring 
constantly,  and  bring  to  a  boil  a  third  time.  Cool  quickly  in 
running  water  and  place  on  ice  until  needed. 

The  mixture  contains  approximately  2  per  cent,  albuminoids, 
1.2  per  cent,  fat,  and  about  12  per  cent,  carbohydrates.     • 

This  preparation,  when  made  according  to  the  above  formula, 
has  a  caloric  value  of  about  700  per  quart. 

In  many  cases  I  have  found  that  children  could  not  tolerate 
as  much  malt  extract  as  given  in  this  formula  without  having 
ing  diarrhoea.  It  is  better  to  begin  with  one-half  ounce  and 
gradually  increase,  if  it  can  be  tolerated,  to  the  full  amount.  If 
this  food  is  given  for  any  length  of  time  some  orange  juice  should 
be  given  to  prevent  scurvy. 

ALBUMIN  OR  CASEIN  MILK 

Another  special  preparation  of  milk,  which  has  been  used 
with  good  results  in  certain  forms  of  intestinal  indigestion  and 
malnutrition,  is  known  in  this  country  by  various  names,  as 
albumin  milk  or  casein  milk.  It  was  described  by  Finkelstein, 
of  Berlin,  under  the  name  of  Eiweis  milk.  It  contains  all  the 
fat  and  casein  of  the  milk,  but  the  salts,  sugar,  and  soluble  al- 
bumin are  eliminated.  As  soon  as  possible  sugar  or  other  car- 
bohydrates are  again  added. 


ARTIFICIAL  FEEDING  133 

Albumin  milk  is  prepared  in  the  following  manner : 

To  one  quart  of  whole  milk  add  one  tablespoon  of  Fairchild's 
essence  of  jx^psin  and  warm  to  100°  ¥.  for  about  one-half  hour, 
or  until  the  milk  is  thoroughly  curdled.  The  "  curds  and  whey  " 
are  then  poured  on  several  thicknesses  of  cheese  cloth  and  al- 
lowed to  drain  for  one-half  hour.  The  whey  which  drains  off  is 
rejected. 

The  curd  is  then  rubbed  through  a  fine  sieve  with  a  spoon, 
gradually  adding  boiled  water  to  the  amount  of  one  pint  during 
the  process.  The  curds  should  be  put  through  several  times,  if 
necessary,  to  make  a  smooth  mixture.  This  gives  a  mechanical 
solution  of  the  curds  of  a  quart  of  milk  in  one  pint  of  water. 
A  pint  of  fresh  buttermilk  is  then  added  and  the  mixture  thor- 
oughly stirred.  It  should  be  put  directly  on  ice  and  kept  there 
until  needed. 

Albumin  milk  has  a  caloric  value  of  from  430  to  500  per 
quart,  depending  upon  the  percentage  of  cream  in  the  curd. 

In  specific  cases  albumin  milk  is  of  great  value.  Many  of 
the  failures  in  its  use  can  be  attributed  to  the  fact  that  it  is  fre- 
quently improperly  made. 

PEPTONIZED    MILK    OR    PREDIGESTED    MILK 

By  peptonized  milk  the  proteids  are  changed  to  peptones.  It 
must  be  remembered  that  if  milk  is  allowed  to  peptonize  beyond 
a  certain  time  it  becomes  bitter  to  the  taste. 

Peptonized  milk  has  a  place  in  the  feeding  of  feeble  infants 
and  in  older  children  where  the  digestive  powers  have  been 
much  reduced  by  illness. 

The  peptonizing  of  milk  should  not  be  kept  up  beyond  the 
time  when  the  digestive  functions  have  been  re-established. 

To  one  pint  fresh  cow's  milk  add  four  ounces  boiled  water, 
two  teaspoons  of  pancreatic  extract,  and  fifteen  grains  of  Sod. 
bicarbonate.  Allow  to  stand  for  ten  to  twenty  minutes  at  a  tem- 
perature of  105°  F.  Then  quickly  bring  to  the  boiling  point  in 
order  to  destroy  the  ferment  and  prevent  further  digestion.     If 


134 


CARE  OF  INFANTS  AND  CHILDREN 


the  milk  is  to  be  used  at  once  the  boiHng  is  unnecessary.  If  it  is 
desired  to  further  peptonize  the  milk  it  is  only  necessary  to  al- 
low it  to  stand  longer  at  the  proper  temperature. 

The  peptonizing  powder  is  put  up  by  Fairchild  in  tubes  of  the 
proper  size  to  peptonize  one  pint  oTmilk.  They  may  be  pur- 
chased one  dozen  in  a  box  at  any  drug  store.  If  the  milk  is 
boiled  some  uncooked  fruit  juice  should  be  given. 

THE   PATENT   FOODS 

The  enormous  growth  in  the  manufacture  and  sale  of  baby 
foods  in  this  country  adds  an  interesting  chapter  to  the  subject 
of  infant  feeding. 

That  some  of  these  foods,  especially  those  which  are  de- 
signed only  to  modify  cow's  milk,  have  in  the  past  served,  and 
are  still  serving,  a  useful  purpose  there  can  be  no  doubt. 

One  of  the  great  evils  for  which  the  manufacturers  of  most 
of  the  patent  foods  are  responsible  is  the  discouragement  to 
breast-feeding,  which  has  resulted  from  the  wide-spread  adver- 
tisements with  which  every  home  is  flooded  long  before  the 
prospective  baby  arrives.  The  ease  with  which  these  foods  can 
be  prepared,  together  with  the  picture  of  a  fat,  although  usually. 
rhachitic,  baby,  is  only  one  of  the  allurements  held  out  to  the 
prospective  mother.  Such  foods  as  Malted  Milk  and  Nestle's 
Food,  although  they  have  a  limited  use,  should  never  be  used  as 
an  exclusive  food  for  infants.  They  are  low  in  fat  and  high  in 
carbohydrates,  and  although  the  proteid  is  present  in  fair  amount, 
the  fact  that  a  large  percentage  of  the  protein  is  of  vegetable 
origin  makes  it  necessary  to  discount  this  element  also.  Accord- 
ing to  Wachenheim,  a  dilution  of  five  ounces  of  Nestle's  Food 
in  one  quart  of  water  gives  the  following  percentage  analysis : 

Proteins    2.1  per  cent. 

Fats     1 .0  per  cent. 

Carbohydrates    14.7  per  cent. 

Salts     0.3  per  cent. 

Water    81 .9  per  cent. 

The  caloric  value  of  this  mixture  is  about  750  per  quart. 


ARTIFICIAL  FEEDING  135 

The  frequency  with  which  children  fed  upon  these  foods 
suffer  from  rickets  should  be  a  sufficient  reason  to  discourage 
their  continuous  use,  unless  combined  with  a  proper  amount  of 
fat  and  proteid. 

•  These  foods  may  sometimes  be  used  to  advantage  for  a  brief 
period  when  children  are  recovering  from  an  acute  intestinal  dis- 
turbance due  to  overfeeding  with  fat.  Malted  Milk  may  be 
given  in  small  amounts  to  supplement  breast-feeding,  especially 
if  the  mother  has  a  scant  supply  but  rich  in  fat. 

When  it  becomes  necessary  to  increase  the  artificial  food, 
cow's  milk  should  always  be  given  in  the  proper  proportion. 

CONDENSED    MILK 

There  is  the  same  objection  to  condensed  as  to  the  other 
proprietary  foods ;  that  is,  the  relatively  low  fat  content  and  the 
high  percentage  of  sugar.  When  it  is  for  any  reason  necessary 
to  give  condensed  milk  it  should  be  supplemented  by  some  other 
food. 

ScirRVY  OR  Barlow's  Disease. — In  addition  to  the  prob- 
ability of  developing  rickets  on  the  patent  foods,  there  is  also 
the  danger  of  scorbutus,  or  scurvy  (Barlow's  disease).  This 
disease  probably  results  from  the  fact  that  these  foods  are  steril- 
ized. Some  uncooked  fruit  juice,  such  as  orange  juice,  should 
always  be  given  to  infants  who  are  being  fed  on  any  sterilized 
food. 

Feeding  During  the  Second  Year 

By  the  end  of  the  first  year  the  baby  has  been  weaned  from 
the  breast.  It  has,  however,  since  the  seventh  or  eighth  month, 
had  other  food  in  increasing  amounts,  the  breast  milk  having 
been  gradually  replaced  by  cow's  milk. 

Quantity  of  Milk  Allowed. — The  question  daily  arises : 
how  much  cow's  milk  should  a  baby  have  during  the  second 
year,  and  is  cow's  milk  necessary  to  the  proper  growth  and  de- 
velopment of  a  child  after  the  first  year? 

It  is  fair  to  assume  that  cow's  milk  was  not  primarily  de- 


136  CARE  OF  INFANTS  AND  CHILDREN 

signed  for  babies  or  children,  but  for  calves,  just  as  a  mother's 
milk  is  designed  for  the  use  of  her  own  baby. 

Undoubtedly,  then,  children  could  get  on  very  well  if  they 
did  not  have  any  milk  after  they  were  weaned. 

There  is  no  doubt  that  milk  is  usually  an  important  addition 
to  the  dietary  of  the  average  child.  There  is  no  doubt,  however, 
that  its  use  in  older  children  has  been  much  overrated. 

It  will  be  found  that  infants  who  are  fed  on  cow's  milk  prac- 
tically to  the  exclusion  of  other  food  are  usually  pale,  flabby  and 
poorly  nourished  generally. 

There  are  some  children  who  are  extremely  intolerant  to 
cow's  milk  and  are  badly  nourished  until  it  is  discontinued  and 
they  are  put  upon  a  good,  round  mixed  diet. 

When  children  have  been  fed  upon  cow's  milk  during  the  first 
year  and  have  had  serious  digestive  disturbance,  particularly  that 
class  who  have  sufTered  from  the  condition  described  by  Czerny- 
Keller  as  Fettnahrschaden,  the  milk  can  be  largely  discontinued 
at  one  year  to  great  advantage,  and  other  food  substituted. 

Unless  children  tolerate  milk  particularly  well,  the  daily  quan- 
tity should  be  cut  to  considerably  below  a  quart  after  the  first 
year,  and  sometimes  earlier. 

The  persistent  constipation  from  which  many  children  suffer 
during  the  first  year  will  frequently  be  much  relieved  when  the 
amount  of  milk  can  be  greatly  reduced. 

Sweets. — The  giving  of  sweets  to  children  in  the  form  of 
candy,  cookies,  etc.,  between  their  meals,  is  to  be  severely  con- 
demned. If  children  are  allowed  sweets  between  their  meals,  or 
in  any  quantity  at  their  meals,  they  will  not  eat  the  proper  amount 
of  plain  food,  such  as  vegetables,  meat,  bread,  and  butter,  etc. 

Whatever  sweets  are  given  should  come  after  the  meal  as  a 
dessert.  It  must  be  distinctly  understood  that  the  plain  food 
must  be  eaten  first,  or  there  will  be  no  dessert. 

Eggs. — Another  article  of  diet  which  is  much  overrated,  par- 
ticularly for  young  children,  is  eggs. 

Some  children,  and  particularly  those  of  the  exudative  type, 


ARTIFICIAL  FEEDING  1 37 

are  intolerant  to  eggs.  It  is  not  uncommon  to  have  a  severe 
urticaria  (hives)  follow  promptly  the  giving  of  an  egg  to  a  young 
child.  When  eggs  are  well  tolerated  they  may  be  given  after  the 
eighteenth  month,  one  every  other  day. 

Many  children  have  an  idiosyncrasy  also  to  such  foods  as 
strawberries  and  shell  fish. 

Before  a  new  food  is  given  in  any  considerable  amount  it 
should  be  tried  in  small  quantities  to  see  whether  it  will  be 
tolerated. 

Alcoholic  drinks,  tea,  and  coffee  should  never  be  given  to 
children. 

Intervals  for  Meals. — During  the  second  year  four  meals 
will  usually  be  sufficient,  given  at  four-hour  intervals.  Up  until 
the  eighteenth  month,  or  until  the  baby  takes  a  good  amount  of 
solid  food  at  a  meal,  some  food  may  have  to  be  given  at  ten 
o'clock  P.M.,  otherwise  the  baby  will  wake  up  very  early  in  the 
morning.  After  ten  o'clock  if  the  baby  wakens  it  should  be 
changed,  if  soiled,  and  given  only  a  little  water,  but  no  food. 

The  following  diet  is  appropriate  for  the  second  year.  The 
bottle  should  now  be  discontinued,  the  baby  having  gradually 
been  taught  to  drink  from  a  cup : 

6  A.M.:  Two  tablespoons  of  thoroughly  cooked  cereal,  such  as^  oat- 
meal, cream  of  wheat,  with  some  of  the  milk  poured  over  it  and  a  trifle 
of  sugar.  Six  to  eight  ounces  of  milk.  If  it  is  more  convenient  at  this 
meal,  a  piece  or  two  of  zwieback  soaked  up  with  milk  may  be  given  instead 
of  the  cereal,  which  may  be  given  at  ten  o'clock. 

9  A.M. :    One  or  two  ounces  of  orange  juice. 

10  A.M. :  One  or  two  pieces  of  zwieback  soaked  up  with  some  of  the 
milk,  SIX  ounces  of  milk  plus  two  ounces  of  barley  or  oatmeal  gruel. 

2  P.M. :  Eight  ounces  good  meat  stock  with  some  unpolished  rice  and 
one  of  the  following  vegetables :  carrots,  spinach,  peas,  beans,  celery, 
asparagus,  all  thoroughly  cooked  and  put  through  a  sieve  and  having  the 
consistency  of  puree.  A  little  baked  or  mashed  potato,  or  toast  soaked  up 
with  one  or  two  ounces  beef  juice,  or  mutton  juice.  After  eighteen 
months,  scraped  meat,  one-half  to  one  tablespoon,  may  be  given  instead 
of  the  meat  juices.  The  meat  should  be  first  broiled  and  then  scraped 
or  finely  ground.    For  dessert :   apple-sauce  or  prune  pulp. 


138  CARE  OF  INFANTS  AND  CHILDREN 

6  P.M. :  Milk  toast,  bread  and  milk,  or  cooked  cereal,  such  as  cream  of 
wheat,  farina,  arrowroot,  rice.     Six  or  eight  ounces  of  milk. 

10  P.M. :  Cup  of  milk.  As  soon  as  a  child  will  take  sufficient  food  at 
four  meals  to  sleep  through  the  night,,  this  feeding  should  be  eliminated. 

Feeding  After  the  Second  Year 
After  a  child  is  two  years  old  it  should  generally  have  but 
three  meals  daily,  and  a  little  lunch  in  the  middle  of  the  fore- 
noon and  afternoon,  if  it  is  hungry,  and  it  is  found  that  such  a 
lunch  does  not  destroy  the  appetite  for  the  regular  meal. 

It  is  well,  so  far  as  possible,  to  make  the  meal  times  cor- 
respond with  those  of  the  family,  as  the  constant  preparation  of 
food  is  liable  to  cause  trouble  in  the  kitchen. 

7  A.M. :  Juice  or  pulp  of  one-half  orange.  Two  tablespoons  well 
cooked  cereal,  oatmeal,  cream  of  wheat,  farina,  with  some  milk  and  very 
little  sugar.  Ready  prepared  malted  foods  are  apt  to  destroy  the  appetite 
for  the  plain  foods  and  should  therefore  be  avoided.  Soft  egg  poached 
or  coddled,  every  other  day,  unless  contraindicated,  or  two  slices  of  lean, 
crisp  bacon  every  other  day  when  the  egg  is  not  given.  Graham  bread  and 
butter.    Cup  of  milk  or  weak  cocoa. 

10  A.M. :   If  hungry,  a  graham  cracker,  or  piece  of  bread  and  butter. 

12  M. :  Soup.  Mashed,  or  baked,  potato.  Scraped,  or  ground,  meat, 
an  amount  equal  to  a  small  lamb  chop.  One  of  the  following  vegetables: 
carrots,  spinach,  peas,  beans,  stewed  celery,  squash,  asparagus  tips,  all 
well  cooked  and  finely  mashed.  Well  cooked  rice,  macaroni,  bread  and 
butter. 

For  dessert :  baked  apple,  apple-sauce,  stewed  prunes,  stewed  peaches 
or  pears  are  the  most  dependable,  or  some  simple  pudding,  as  sago, 
tapioca,  or  custard,  may  be  given.  Pineapple  and  other  uncooked  fruits, 
unless  mashed,  are  liable  to  be  swallowed  without  proper  mastication  and 
often  produce  gastric  disturbance. 

3  P.M.:  If  hungry,  and  it  is  found  that  it  does  not  interfere  with 
supper,  a  piece  of  zwieback  or  a  plain  cracker  may  be  permitted. 

5.30  P.M. :  Milk  toast,  cereal,  bread  and  butter,  custard,  bread  pudding, 
stewed  fruit.    Milk. 

The  following  articles  of  diet  are  generally  forbidden  to 
young  children : 

Meats. — Pork,  with  the  exception  of  crisp  bacon,  corned  beef,  salted  fish, 
and  fried  meat  generally. 


ARTIFICIAL  FEEDING 


139 


Vegetables. — Fried  vegetables  generally,  cabbage,  raw  onions,  radishes, 

cucumbers,  raw  tomatoes,  green  corn. 
Bread  and  Pastry. — Hot  bread  and  rolls.    All  cake  and- candy,  except  the 

simplest  kinds,  and  then  only  in  small  amount  as  dessert,  after  the  meal. 
Drinks. — Tea  and  coffee,  and  all  beverages  containing  alcohol. 

Discipline  in  the  Feeding  of  Children 

From  the  first,  infants  should  have  regular  times  for  their 
meals. 

Children  should  not  be  consulted  about  what  they  want  to 
eat.  If  they  are  allowed  to  choose  their  own  diet,  they  will 
naturally  choose  what  appeals  most  to  their  taste,  without  re- 
gard to  digestibility  or  food  value. 

It  is  perfectly  foolish  to  say  that  a  child  will  not  eat  this  or 
that  food.  A  child  will  eat  any  wholesome  food  which  is  put 
before  it,  if  it  is  hungry  enough. 

It  is  fatal  to  discipline,  if  a  child  is  allowed  to  refuse  some 
particular  food  and  cry  until  he  gets  what  he  wants. 

Children  must  be  given  the  proper  food,  and  if  they  are  not 
hungry  enough  to  eat  it,  a  period  of  starvation  for  a  couple  of 
meals  will  add  an  excellent  sauce,  after  which  the  same  food 
will  be  eaten  with  relish. 

Children  who  are  permitted  to  pick  and  choose  at  their  meals 
are  a  nuisance  throughout  life,  both  to  themselves  and  every  one 
with  whom  they  come  in  contact. 

Poor  Appetite. — There  is  no  doubt  that  some  children  are 
much  more  difficult  to  feed  than  others.  In  other  words,  there 
are  "  good  feeders  "  and  "  bad  feeders."  Some  children,  usually 
nervous  and  badly  nourished  from  infancy,  have  a  small  toler- 
ance for  food  and  after  eating  a  small  amount  are  satisfied. 
Their  appetites  are  capricious  and  they  usually  crave  just  the 
things  they  should  not  have :  sweets  and  highly  seasoned  food. 
It  is  a  great  mistake  to  cater  to  the  appetites  of  such  children, 
for,  of  all  children,  they  especially  should  have  the  plain  nourish- 
ing food,  with  a  practical  elimination  of  sweets.  When  children 


I40  CARE  OF  INFANTS  AND  CHILDREN 

are  unduly  excited  they  should  not  be  forced  to  eat,  as  they  will 
usually  suffer  from  an  attack  of  indigestion  as  a  result. 

School  Children. — The  diet  of  school  children  should  be 
carefully  watched.  Unless  careful  discipline  as  to  hours  for  go- 
ing to  bed  and  rising  in  the  morning  is  strictly  enforced,  children, 
for  fear  of  being  late  for  school  or  the  play,  are  liable  to  go  off 
without  sufficient  breakfast,  and  that  which  they  do  eat  is  usu- 
ally improperly  masticated.  At  noon,  the  time  is  just  long  enough 
to  be  able  to  repeat  the  program  of  the  morning.  Many  chil- 
dren take  their  lunch  to  school  and  eat  it  cold,  the  food  often 
being  badly  chosen  for  the  needs  of  a  growing  child. 

The  result  is  that  such  children  are  often  poorly  nourished, 
nervous,  and  are  apt  to  break  down  physically  and  nervously. 
The  question  of  diet  for  school  children  offers  a  large  and  im- 
portant field  for  the  social  worker  and  school  nurse,  and  one  in 
which  proper  knowledge  and  effort  will  be  well  rewarded  by  the 
results. 


CHAPTER  XIII 
PUBERTY 

Puberty  is  the  transition  period  between  childhood  and 
adolescence.  The  age  of  puberty  begins  earlier  in  girls  than  in 
boys,  the  average  for  girls  being  13  years  and  for  boys  15  years. 

As  this  time  approaches  the  child  shows  evidence  of  change, 
both  physically  and  mentally.  Instead  of  the  tom-boy  girl,  who 
romped  with  boys  and  girls  alike,  we  begin  to  notice  a  reticence 
and  discrimination  of  sex.  In  girls,  the  breasts  begin  to  develop, 
and  a  growth  of  hair  appears  under  the  arms  and  about  the 
genitals.  Menstruation  begins  usually  from  the  I3-I4th  year, 
occasionally  as  early  as  the  12th. 

The  first  evidence  of  the  approach  of  adolescence  in  boys  is 
often  a  change  in  the  quality  of  the  voice,  and  at  the  same  time 
there  is  a  growth  of  hair  under  the  arms  and  about  the  genitals. 

During  this  time  there  is  liable  to  be  a  marked  instability  of 
the  nervous  system.  Children  are  prone  to  be  irritable  and  there 
is  a  greater  tendency  during  this  time  to  nervous  affections. 
Girls  frequently  suffer  from  anaemia. 

The  age  of  puberty  should  be  considered  one  of  the  critical 
periods  in  the  life  of  the  individual. 

During  this  period  children  should  not  be  crowded  with  their 
studies,  and  if  the  general  health  is  below  par  the  child  should 
be  taken  out  of  school  for  a  time  and  sent  to  the  country,  and 
sometimes  away  from  the  other  members  of  the  family. 

Only  plain,  nutritious  food  should  be  permitted. 

Many  children  are  prone  to  sit  about  and  read  sentimental 
novels,  or  frequent  morbid  picture  shows,  when  they  should  be 
playing  out  of  doors.  This,  of  course,  should  be  discouraged, 
and  the  child  should  be  kept  interested  in  out-of-door  pursuits, 

141 


142 


CARE  OF  INFANTS  AND  CHILDREN 


which  will  tend  to  develop  both  the  physical  and  moral  side  of 
his  or  her  nature. 

A  proper  amount  of  intelligent  supervision  during  this  period 
of  a  child's  life  will  be  repaid  many  fold. 

Painful  and  irregular  menstruation  in  girls  should  always 
be  brought  to  the  attention  of  the  physician,  as  it  is  frequently 
due  to  a  simple  secondary  anaemia,  which  can  usually  be  readily 
corrected.  Under  no  circumstances  should  local  examinations  or 
treatment  be  permitted  except  for  urgent  medical  indications. 


CHAPTER  XIV 
DELICATE  CHILDREN 

Some  children  are  delicate  from  birth.  They  often  inherit  a 
poor  constitution  from  the  father  or  mother,  or,  owing  to  some 
illness  of  the  mother,  the  baby  is  improperly  nourished  and  may 
be  born  prematurely,  or,  if  at  full  term,  much  under  weight  and 
lacking  in  vitality.  The  milk  supply  under  such  conditions  is 
liable  to  be  lacking  in  quantity  and  quality  and  should  be  supple- 
mented by  extra  feeding. 

It  is  in  such  cases  as  these  that  the  prenatal  care  of  mother 
and  child  would  avail  much.  Many  of  the  delicate  children, 
however,  are  normal  at  birth,  and  their  subsequent  delicate  con- 
dition can  be  attributed  to  improper  feeding.  Many  of  them  are 
fed  upon  one  of  the  patent  foods  and  suffer  from  rickets  as  a 
result. 

Such  children  are  pale,  thin,  with  poorly  developed  chests, 
frequently  of  the  phthisical  variety,  or  showing  the  effects  of 
early  rickets.  Not  infrequently  the  glands  in  the  neck  are  larger 
than  normal.  These  children  are  easily  fatigued,  lack  energy, 
eat  badly  and  with  a  capricious  appetite.  They  are  usually  of  an 
unstable  disposition,  frequently  spoiled,  and  are  in  constant 
trouble  with  other  members  of  the  family  as  a  result.  Examina- 
tion may  reveal  no  definite  diseased  condition. 

If  anything  worth  while  is  to  be  done  for  this  class  of  chil- 
dren it  must  be  by  intelligent,  skilful  handling. 

Such  children  should  be  taken  away  from  the  family  for  a 
period,  preferably  into  the  country,  on  a  farm.  One  must  be 
careful,  however,  to  choose  a  boarding-place  where  fresh  meat, 
vegetables,  eggs,  milk,  and  fruit  may  be  procured,  and  where  they 
can  be  properly  prepared,  as  there  is  no  place  in  the  world  where 
good  food  is  so  often  spoiled  in  the  cooking  as  on  the  farm. 

M3 


144  CARE  OF  INFANTS  AND  CHILDREN 

Where  the  chest  is  undeveloped,  as  it  generally  is  in  these 
cases,  systematic  deep  hreathing,  combined  with  proper  muscular 
exercises,  will  do  much  to  correct  the  condition.  Proi>er  posture 
while  sitting,  standing,  and  walking  should  be  insisted  upon. 


Fig.  66. — Screened  house  and  tent. 


A  great  effort  should  be  made  to  get  such  children  vitally  in- 
terested in  some  pursuit  which  requires  much  walking  and  climb- 
ing, as,  for  example,  the  study  of  birds  and  their  nests,  or  the 
collection  of  all  the  varieties  of  wild  flowers  in  the  vicinity. 


DELICATE  CHILDREN  145 

It  is  wonderful  what  a  difference  it  makes  in  one's  attitude 
toward  life,  if  one  does  a  thing  voluntarily,  instead  of  being 
coaxed  or  driven. 

Many  of  these  children,  and  particularly  the  girls,  suffer 
from  a  general  ptosis  of  all  the  abdominal  organs.  This  is  a 
result  of  improper  support  from  the  ligaments,  and,  unless 
corrected  by  proper  posture  and  exercise,  it  frequently  leads  to 
serious  disturbance  in  later  life. 

These  children  should  sleep  out  of  doors  the  entire  summer, 
and  winter  also,  when  the  weather  is  not  too  severe  (Fig.  66). 
The  windows  should  always  be  sufficiently  open  to  keep  the  air 
thoroughly  fresh. 

Cod-liver  oil  is  of  undoubted  advantage  in  some  cases,  but  if 
the  digestion  is  disturbed  as  a  result,  it  does  more  harm  than 
good. 


CHAPTER  XV 

DISEASES  OF  NUTRITION 

The  wasting  diseases  of  infants  are  acute  or  chronic.  The 
terms  "  inanition,"  "  malnutrition,"  and  "  marasmus  "  are  usually 
used. to  designate  different  stages  of  the  same  condition. 

Acute  inanition,  or  acute  atrophy,  is  usually  due  to  insuffi- 
cient fluid  being  supplied  the  tissues,  or  to  sudden  loss  of  fluid, 
or  to  both  combined. 

A  common  cause  of  acute  simple  atrophy  is  insufficient  food. 
It  is  not  infrequently  seen  in  breast-fed  infants  where  the  milk 
is  insufficient  in  quantity.  The  rapid  loss  in  weight  in  babies 
suffering  from  pylorospasm  or  pyloric  stenosis,  is  an  excellent 
example  of  acute  inanition  or  atrophy. 

Effects  of  Bad  Feeding. — Infants  who  are  badly  fed,  par- 
ticularly on  high  fat  mixtures  of  cow's  milk,  not  infrequently 
suffer  such  damage  to  the  digestive  apparatus  that,  in  spite  of 
fairly  large  amounts  of  food,  they  continue  to  lose  weight  until 
such  an  extreme  degree  of  emaciation  is  reached  that  death  often 
results,  apparently  from  starvation  (Figs.  67  and  68). 

Inherited  Weakness. — Many  of  these  children  are  born 
under  unfavorable  conditions,  the  parents  are  not  vigorous  and 
may  be  suffering  from  the  effects  of  latent  tuberculosis  or 
syphilis.  At  autopsy  some  of  these  infants  are  found  to  have 
tuberculosis.  In  some,  ulcers  of  the  duodenum  are  found,  but 
whether  as  cause  or  effect  is  not  yet  known. 

Prognosis. — In  the  acute  form,  the  prognosis  is  usually  good 
when  due  to  simple  starvation,  and  all  that  is  required  to  bring 
about  a  cure  is  to  supply  a  proper  amount  of  breast  milk.  Those 
due  to  obstruction  at  the  pylorus  will  require  the  appropriate 
treatment,  either  medical  or  surgical.  This  has  been  described 
under  "  Vomiting," 
146 


DISEASES  OF  NUTRITION 

Fig.  67 


147 


1 


Fig.  68 
Fig.  67. — Simple  atrophy  or  marasmus  in  child  eight  months  old.     (St.  Paul   City  and 
Fig.  68 


County  Hospital.) 
Same  case  after  three  months  of  proper  feeding  and  care.     (St.  Paul  City  and 


County  Hospital.) 

The  chronic  cases  are  the  ones  which  tax  the  ingenuity  and 
patience  of  all  concerned. 

Tre.atment. — When  the  atrophy  is  due  to  the  food,  the 
offending  element — whether  fat,  sugar  or  salts — must  be  de- 


148 


CARE  OF  INFANTS  AND  CHILDREN 


termined  and  eliminated.  Even  when  these  cases  are  placed 
upon  a  proper  diet  they  must  pass  through  a  period  of  _  repair 
which  may  require  several  weeks  or  months  before  any  marked 
improvement  may  be  noticed.  The  securing  of  at  least  some 
breast  milk  is  of  vital  importance. 

The  bowels  require  special  care,  as  the  markedly  atrophic 
muscles  have  not  sufficient  force  to  produce  normal  evacuation. 


Fig.  69. — Rectal  irrigation. 

Injections  of  half  an  ounce  of  olive  oil  will  usually  result  in  a 
good  evacuation  and  do  no  harm.  Occasionally  irrigations  with 
normal  salt  solution  may  be  necessary  to  empty  the  colon  of 
impacted  faeces  (Fig.  69).  General  massage  is  of  the  greatest 
benefit,  and  night  and  morning,  for  15  minutes,  olive  oil  or 
cocoanut  oil  should  be  rubbed  into  the  skin. 

Ar.-scRssES  IN  THE  Sktn. — Abscesses  of  the  skin  are  common 
and  should  be  opened  at  the  proper  time.     Great  judgment  must 


DISEASES  OF  NUTRITION  I49 

be  exercised  in  the  feeding  of  these  cases ;  their  tolerance  is 
usually  small  at  first,  and  if  exceeded,  the  result  is  always  a 
backward  step.  They  should  be  kept  in  the  open  as  much  as 
possible  and  allowed  all  the  freedom  their  muscles  are  capable  of. 
Prognosis. — After  these  cases  begin  to  improve  and  the 
digestion  becomes  normal,  it  is  marv^ellous  how  rapidly  they 
increase  in  weight  and  strength,  so  that  at  18  months  they  are 
sometimes  almost  as  far  advanced  as  the  normal  child  at  that  age. 

Rickets 

Rickets  is  a  disorder  of  nutrition,  occurring  usually  within 
the  first  two  years  of  life,  and  due  to  faulty  diet  and  improper 
hygienic  surroundings. 

Etiology. — Rickets  is  first  mentioned  in  the  English  medical 
literature  as  early  as  1604,  and  has  been  generally  known  on  the 
continent  of  Europe  as  the  "  English  Sickness,"  although  it  is 
now  quite  as  common  on  the  Continent  as  in  England.  The 
disease  has  increased  greatly  with  the  introduction  of  artificial 
feeding,  and  particularly  with  the  proprietary  foods.  It  is  rare 
to  see  a  baby  who  has  been  fed  exclusively  on  condensed  milk 
or  one  of  the  desiccated  malted  foods,  who  is  not  suffering  from 
rickets  to  some  degree.  The  races  of  the  extreme  South  and 
extreme  North  are  rarely  affected  by  the  disease  when  they 
remain  in  their  own  country.  When,  however,  Italians  or 
negroes  go  North,  their  children  usually  suffer  from  rickets,  and 
often  in  an  aggravated  form.  A  diet  poor  in  fat  seems  to  pre- 
dispose to  the  disease.  Experiments  have  shown  that  young 
lions  who  were  weaned  early  and  fed  exclusively  on  raw  meat 
developed  the  disease.  Upon  the  addition  of  milk  and  cod-liver 
oil  they  were  soon  cured. 

Symptoms. — Although  the  most  marked  changes  are  in  the 
skeleton,  the  first  symptoms  are  usually  constitutional.  The 
baby  is  fretful,  sleeps  badly,  and  when  it  is  taken  up  the  pillow 
where  the  head  has  rested  is  often  wet  with  perspiration. 
(There  is  often  a  spot  on  the  back  of  the  head  the  size  of  the 
palm  of  the  hand  where  the  hair  has  been  completely  rubbed 


I50 


CARE  OF  INFANTS  AND  CHILDREN 


off  from  rolling  the  head  about  on  the  pillow.)  There  is  often 
a  slight  elevation  of  temperature.  Tenderness  of  the  bones  is 
often  an  early  symptom,  and  when  the  baby  is  raised  in  the 
ordinary  manner,  or  if  the  legs  are  touched,  it  cries  as  if  in  pain. 
Not  infrequently,  after  the  baby  has  begun  to  walk  it  suddenly 


Fig.  70. 


Fig.  71. 


Fig.  70. — Characteristic  sitting  position  of  a  child  with  rickets. 
Fig.  71. — Bow-legs.     (Willard's  Childhood  Surgery.) 

ceases  again,  and  sits  with  legs  crossed  and  cannot  be  persuaded 
to  make  the  effort  to  stand  or  walk  (Fig.  76). 

Changes  in  the  Bones. — Later  there  is  marked  evidence 
of  changes  in  the  bones.  The  enlargement  of  the  epiphyses  at 
the  wrists  and  ankles  and  the  rhachitic  rosary  (Fig.  78),  the 


DISEASES  OF  NUTRITION 


151 


beaded  condition  of  the  junction  of  the  ribs  and  sternum,  are 
early  evidences  of  the  changes  in  the  bones. 

Bow-LEGS. — Later  there  may  be  marked  deformity  of  the  long 
bones  of  the  legs  or  arms,  and  of  the  spine.  "  Every  case  of 
bow-legs  is  the  result  of  rickets  "  (Figs.  71  and  72). 

The  changes  in  the  shape  of  the  pelvis  in  girls  may  later  in 
life  result  in  great  difficulty  in  the  bearing  of  children. 

Craniotabes. — The  bones  of  the  head  often  show  marked 
changes.    They  are  sometimes  so  soft 
that  they  can  be  dented  like  the  case 
of  a  watch — a  condition  known-  as 
craniotabes. 

Open  Fontanelles. — The  ante- 
rior fontanelle  is  usually  large  and 
markedly  delayed  in  closing. 

The  Teeth. — The  eruption  of 
the  teeth  is  usually  delayed,  the  teeth 
coming  at  irregular  times.  They 
are  prone  to  early  decay  as  a  result 
of  improper  development  of  the 
enamel. 

The  head  of  the  rhachitic  child 
has  later  a  peculiarly  square  appearance,  due  chiefly  to  a  marked 
thickening  of  the  frontal  and  parietal  bones  (Fig.  73). 

Deformities  of  the  chest — pigeon-breast  (Fig.  74),  Harrison's 
groove — and  deformities  of  the  spine — scoliosis,  lordosis,  and 
kyphosis  (Figs.  75,  76,  and  yj) — are  common  in  rickets. 

Prophylaxis. — To  prevent  rickets,  keep  the  baby  on  the 
breast,  and  if  the  mother  has  not  sufficient  milk,  the  deficiency 
should  be  made  up  with  cow's  milk. 

Treatment. — When  infants  are  suffering  from  rickets,  early 
recognition  and  the  institution  of  a  proper  diet  are  of  vital 
importance.^ 

*  A  diet  relatively  high  in  fat  and  low  in  carbohydrates  is  indicated. 
Cod-liver  oil  and  phosphorus  is  supposed  to  be  a  specific. 


Fig.   72. — Knock-knee  resulting 
from    rickets. 


152  CARE  OF  INFANTS  AND  CHILDREN 

It  is  much  easier  to  prevent  deformities  than  to  correct  them. 

When  deformities  have  already  begun  much  may  be  done  by 
proper  apparatus  in  the  hands  of  a  skilful  physician  to  prevent 
further  deformity  and  to  correct  those  already  present. 

Scurvy,  Scorbutus  (Barlow's  Disease) 
Etiology. — Scurvy  is  a  disease  of  nutrition,  resulting  from 
improper  food  and  particularly  from  the  exclusive  use  of  a  food 


Fig.  73. — Square  shaped  head  characteristic  in  severe  rickets. 

which  has  been  sterilized.  The  disease  is  probably  the  same 
from  which  sailors  suffered  in  the  days  of  sailing  vessels,  when 
they  were  forced  to  exist  for  long  periods  without  any  fresh  fruit 
or  vegetables  in  their  diet. 

Since  the  patent  foods  have  come  into  such  general  use,  the 
number  of  cases  of  scurvy  in  infants  has  markedly  increased. 


DISEASES  OF  NUTRITION 


153 


Scurvy  in  children  was  formerly  thought  to  be  one  of  the 
symptoms  of  a  severe  rickets.  It  was  demonstrated  by  Sir 
Thomas  Barlow  in  1883  to  be  a  separate  disease.     It  is  common, 


Fig.  74. — Pigeon-breast,  resulting  from  rickets. 


however,  to  have  both  diseases  occurring  in  the  same  patient  at 
the  same  time  (Fig.  78). 

Symptoms. — The  disease  is  characterized  by  pain  and  tender- 
ness along  the  shafts  of  the  bones,  due  to  subperiosteal  hemor- 
rhages. The  child  frequently  screams  with  pain  when  being 
changed  or  otherwise  handled.  Such  sensibility  is  always  sig- 
nificant and  should  awaken  the  riurse's  suspicion  as  to  the  pos- 


154 


CARE  OF  INFANTS  AND  CHILDREN 


sibility  of  scurvy.  These  hemorrhages  sometimes  later  invade 
the  tissues  and  may  be  seen  as  yellow  areas  where  the  tissues 
and  skin  have  been  stained  by  the  blood  pigment.  Hemor- 
rhages around  the  eyes  with  ecchymosis  resembling  "  black  eye," 
occur  occasionally  in  these  cases  (Fig.  78). 

Hemorrhages  around  the  teeth  are  characteristic  and  are  seen 
as  a  blue  line  on  the  margin  of  the  gums,  and  it  is  not  uncom- 
mon to  see  a  blood-blister  over  the  crown  of  a  prospective  tooth. 


Fig.  7,^ 


Fig.  76 


Fig. 


Fig.  75. — Scoliosis  resulting  from  rickets. 
Fig.  76. — Lordosis,  resulting  from  rickets. 
Fig.  77. — Kyphosis,  resulting  from  rickets. 

,  There  is  usually  marked  anaemia.  These  cases  are  bad  sub- 
jects for  surgery,  as  the  hemorrhage  is  difficult  to  check  owing 
to  the  slowness  with  which  the  blood  clots. 

Prevention. — Rabies  on  the  breast  never  develop  scurvy. 
When  children  are  fed  on  any  sterilized  food,  either  cow's  milk 
or  the  proprietary  foods,  some  uncooked  fruit  or  vegetable  juice 
should  be  given  daily. 


DISEASES  OF  NUTRITION  155 

Treatment. — When  scurvy  has  already  developed,  orange 
juice  is  a  specific.  If  orange  juice  is  too  laxative  some  other 
uncooked  fruit  juice  should  be  given.  The  anicmia  and  associ- 
ated rickets  will  gradually  disappear  under  the  proper  food  and 
rtiedication. 

Purpura,  Mel^na  Neonatorum,  and  Hemophilia 

PURPURA 

"  Purpura  is  the  name  applied  to  the  spontaneous  extravasa- 
tion of  blood  in  and  beneath  the  skin  and  mucous  membranes.'* 


Fig.   78. — A  case  of  scurvy  in  a  child  of  six  months,  showing  the  hemorrhage  around  the  left 
eye.   Showing  also  a  pronounced  rhachitic  rosary.    (Courte.sy  of  Dr.  P.  H.  Bennion.) 

The  symptoms  are  the  chief  features  of  the  disease,  the  cause 
being  frequently  unknown. 

A  variety  of  forms  were  formerly  described  as :  purpura 
simplex,  purpura  rheumatica,  purpura  hsemorrhagica,  purpura 
toxica,  etc 

It  is  probable  that  the  condition  is  practically  always  due  to 
some  infection,  or  to  the  eflFect  of  bacterial  products. 

A  clear  analysis  of  the  symptoms,  including  a  careful  analysis 
of  blood  and  urine,  will  frequently  give  a  clue  to  the  cause  of  the 
hemorrhages. 

MELiENA   NEONATORUM    (tHE    HEMORRHAGIC   DISEASE) 

These  terms  are  meant  to  designate  a  form  of  bleeding  which 
occurs  spontaneously  in  the  new-born.  The  bleeding  most  fre- 
quently occurs  on  the  second  or  third  day,  although  it  may  begin 


156  CARE  OF  INFANTS  AND  CHILDREN 

a  few  hours  after  birth.  The  most  common  site  of  bleeding- 
is  the  bowel,  the  blood  appearing  in  the  stool,  either  clotted  or 
in  liquid  form,  mixed  with  the  meconium.  The  next  most  com- 
mon site  of  the  bleeding  is  the  stomach,  in  which  case  the  blood 
is  usually  vomited.  Bleeding  may  occur  from  the  nose  or  any 
of  the  mucous  membranes,  and  I  have  seen  in  one  case  large 
amounts  of  blood  passed  in  the  urine.  The  cause  of  the  disease 
is  not  known.  The  condition  is  serious,  but  not  necessarily 
fatal.  Under  favorable  conditions  there  is  a  mortality  of 
probably  less  than  50  per  cent. 

Treatment. — Satisfactory  results  have  followed  the  use  of 
gelatin  both  by  mouth  and  by  hypodermic  injection.  A  5  per 
cent,  solution  of  ordinary  flake  gelatin  is  made  in  water,  or  i 
ounce  of  gelatin  in  20  ounces  of  water.  The  solution  should  be 
boiled  in  order  to  sterilize  it,  as  anthrax  bacilli  have  not  infre- 
quently been  found  in  gelatin.  The  baby  may  be  given  a  small 
amount  every  hour,  1-2  teaspoons,  or  5^  to  i  ounce  every  three 
or  four  hours,  by  mouth.  For  subcutaneous  injection  a  10  per 
cent,  solution  should  be  used,  i  to  2  drachms  being  injected 
every  three  or  four  hours,  until  the  bleeding  stops.  Gelatin 
is  now  put  up  by  manufacturing  chemists  in  the  proper  amounts 
for  hypodermic  use. 

In  the  use  of  so  large  an  amount  as  5ii  hypodermically,  great 
care  must  be  taken  not  to  produce  sufficient  trauma  in  the 
tissues  as  to  result  in  abscess  formation.  After  the  injection 
the  area  should  not  be  massaged  to  promote  absorption.  Gelatin 
is  supposed  to  be  efficacious  owing  to  the  amount  of  calcium  it 
contains.  Calcium  may  be  given  by  mouth  in  the  form  of 
calcium  lactate  grains  x  to  xx  three  times  daily  with  the  food. 

Transfusion  of  Blood. — Transfusion  of  blood  from  the 
veins  of  another  person  to  those  of  the  infant  has  been  much 
practised  of  late,  and  with  beneficial  results.  The  technic  is 
difficult  and  requires  great  skill  and  considerable  experience.  A 
simple  manner  of  transfusion  is  to  withdraw  blood  from  the 
vein  of  one  person  by  means  of  a  cannula  and  introduce  it  into 


DISEASES  OF  NUTRITION  157 

the  vein  or  tissue  of  the  infant  by  means  of  a  large  hypodermic 
syringe.  Considerable  difificulty  is  experienced  in  keeping  the 
blood  from  clotting  long  enongh  to  be  introduced.  To  this  end, 
a  paraffin-lined  tube  (Kimpton-Brown)  and  sterilized  normal 
salt  solution  should  always  be  at  hand.  The  greatest  care  and 
thoroughness  in  the  cleansing  of  the  skin,  as  well  as  all  instru- 
ments, should  be  exercised.  Hypodermic  injections  of  human 
blood  serum  and  horse  serum  have  been  used  with  varying 
degrees  of  success. 

HEMOPHILIA 

The  disease  known  as  haemophilia,  meaning  a  tendency  to 
bleed,  is,  according  to  all  authorities,  rare  in  infancy  and  early 
childhood,  if,  indeed,  it  occurs  at  all.  After  the  second  or  third 
year  it  is  not  uncommon.  The  disease  is  distinctly  hereditary, 
being  frequently  traced  through  seven  or  eight  generations. 
The  males  are  more  liable,  twelve  to  one,  to  be  affected  than 
the  females,  although  it  is  more  liable  to  be  transmitted  through 
the  mother,  usually  without  herself  being  affected. 

Whenever  a  history  of  hsemophilia  is  obtainable,  even  if  it 
is  ever  so  remote,  no  surgical  procedure  should  be  undertaken 
except  under  great  compulsion.  The  surgeon  should  always  be 
informed  if  there  is  the  least  suspicion  of  bleeding  in  the  family. 


CHAPTER  XVI 
JAUNDICE  IN  BABIES.     (ICTERUS) 

Jaundice  may  be  roughly  divided  into  two  classes  : 

1.  A  physiological  jaundice  from  which  a  large  percentage  of 
new-born  infants  suffer  and  which  disappears  in  a  week  or  ten 
days  without  leaving  any  apparent  injurious  effect.  This  con- 
dition is  known  as  icterus  neonatorum. 

2.  A  pathological  jaundice  due  to  congenital  obliteration  of 
the  bile-ducts  or  to  some  inflammatory  condition. 

Holt  found  jaundice  in  33.3  per  cent,  of  new-born  infants  and 
some  authorities  in  a  much  larger  percentage. 

Etiology. — There  have  been  many  explanations  as  to  the 
cause  of  icterus.  The  most  plausible  one  is  offered  by 
Knapfelmacher,  who  holds  that  during  the  first  few  days,  owing 
to  the  activity  of  the  bile  cells,  the  capillaries  become  blocked 
with  tenacious  bile,  resulting  in  bile  pigment  being  absorbed  into 
the  blood  stream.  The  condition  is  not  fatal  and  needs  no 
treatment. 

Jaundice  from  congenital  obliteration  of  the  bile-ducts  is  rare 
and  ends  fatally. 

Catarrhal  Jaundice. — In  older  children,  catarrhal  jaundice 
due  to  an  inflammation  of  the  common  bile-ducts,  extending 
from  the  bowel  and  producing  sometimes  grave  symptoms,  is  not 
uncommon.  Catarrhal  jaundice  occurs  not  infrequently  in  epi- 
demics. During  the  acute  stage  there  is  often  marked  depression 
of  the  circulation. 

Gall-stones. — Jaundice  in  children  as  a  result  of  gall-stones 
is  extremely  rare. 

Diet. — The  simplest  diet  should  be  given  and  the  bowels 
kept  open  with  some  simple  saline,  such  as  sodium  phosphate  or 
milk  of  magnesia.     The  patient  should  be  kept  in  bed. 

Bile  in  the  Urine. — In  all  forms  of  jaundice  the  bile  is 
eliminated  in  the  urine,  as  well  as  in  the  perspiration. 
158 


CHAPTER  XVII 
THE  URINE 

"  The  kidneys  undoubtedly  functionate  during  the  last  weeks 
of  intra-uterine  life,  and  the  bladder  has  been  found  distended 
with  urine  at  birth."  Urine  is  frequently  passed  directly  after 
birth,  after  which  it  may  not  be  again  voided  during  the  next 
twenty-four  hours,  a  fact  which  gives  many  nurses  and  mothers 
great,  but  unnecessary,  concern.  The  first  urine  passed  is  usually 
pale  in  color  and  of  a  low  specific  gravity.  As  the  baby  gets 
more  milk  from  the  mother,  the  urine  gradually  assumes  an 
amber  color.  Not  infrequently  there  are  small  yellow  or  reddish 
brick-dust  deposits  on  the  diaper.  They  are  made  up  of  am- 
monium urate  and  uric  acid  and  have  no  special  significance. 

Quantity  of  Urine. — The  quantity  of  urine  secreted  during 
the  first  few  days,  or  at  any  time  for  that  matter,  depends  largely 
upon  the  amount  of  fluid  taken.  During  the  first  few  days  the 
amount  of  urine  will  be  small  unless  water  is  given  freely,  as 
there  is  little  secretion  of  milk  up  to  this  time. 

In  breast-fed  babies  the  amount  of  urine  will  usually  be 
less  than  in  those  fed  on  artificial  food,  since  the  quantity  of 
liquid  consumed  is  usually  less.  Infants  who  are  allowed  to  go 
to  sleep  with  a  bottle  of  water  will  consequently  secrete  a  large 
amount  of  urine. 

The  following  quantities  represent  approximately  the  normal 
amount  of  urine  which  should  be  passed  at  different  ages : 

Age  Amount  in  ounces 

1st  day    >4  to     2  ounces. 

7th  day  6      to  lo  ounces. 

I  mo'.th    ID      to  14  ounces. 

3  months     15      to  17  ounces. 

6  months    17      to  20  ounces. 

12  months    20      to  25  ounces. 

Frequency  of  Urination. — There  is  a  marked  difference  in 

159 


l6o  CARE  OF  INFANTS  AND  CHILDREN 

infants  as  to  the  frequency  with  which  they  pass  urine.  When 
young  infants  are  getting  a  normal  amount  of'  food  they  pass 
urine  every  hour  or  two  when  awake,  but  may  retain  it  for  three 
or  four  hours  while  asleep.  The  amount  of  fluid  taken  will 
usually  determine  the  frequency  under  normal  conditions. 

Bladder  Control. — Children  do  not  usually  gain  control  of 
the  bladder-function  before  they  are  two  and  a  half  to  three 
years  of  age,  but  with  careful  training  and  occasional  mishaps, 
they  may  be  taught  control  considerably  earlier.  (For  incon- 
tinence, see  page  163.) 

Reaction. — The  reaction  of  the  urine  in  the  new-bom  is 
usually  distinctly  acid.  For  the  rest  of  life  it  is  normally  faintly 
acid  or  neutral.  The  specific  gravity  for  the  first  day  is  loio 
to  1012.  From  that  time  until  the  child  is  two  years  old,  it 
varies  normally  from  1004  to  1012,  and  does  not  reach  that  of 
the  adult,  1020,  until  the  child  has  reached  the  age  of  six  to 
eight  years 

Clinical  Examination  of  the  Urine. — The  examination 
of  the  urine  in  infancy  and  childhood  is  of  the  greatest  clinical 
significance.  In  all  cases  of  illness  in  infants  and  children  the 
urine  should  be  systematically  examined  by  the  physician.  In 
order  that  he  be  able  to  do  this,  a  specimen  of  the  urine  must  be 
secured.  This  is  not  usually  difficult.  If  the  baby  is  watched 
for  an  hour  or  so,  and  the  diaper  allowed  to  remain  off,  a 
specimen  can  usually  be  secured  if  a  receptacle  is  at  hand. 
Placing  a  cold  sponge  over  the  bladder  will  often  result  in  the 
baby  voiding  urine.  In  male  infants  it  is  a  simple  matter  to 
attach  a  small  bottle  with  a  strip  of  adhesive  plaster  so  that  the 
baby  will  pass  urine  directly  into  the  bottle.  For  female  infants 
a  rubber  glove  finger  stretched  over  the  neck  of  a  bottle  or  test- 
tube  and  attached  around  the  vulva  by  a  strip  of  adhesive  plaster 
will  result  in  a  specimen  being  secured  (Figs.  79  and  80). 

In  securing  urine  from  female  children  great  care  must  be 
taken  first  to  thoroughly  cleanse  the  parts  around  the  urethra, 
otherwise  contamination  from  external  secretions  may  compli- 


THE  URINE 


l6i 


cate  the  findings,  particularly  under  the  microscope.  When 
urine  cannot  be  examined  at  once  it  should  be  kept  on  ice,  as 
urine  which  stands  for  a  few  hours  in  a  warm  room  will  rapidly 


i''lG.   79. — Simple  device    for  securing  a  specimen  of    urine  from  female  infants. 


undergo   decomposition   and    develop   myriads   of   bacteria   of 
various  kinds. 

Normal  Constituents  of  the  Urine. — The  chief  normal 
constituents  of  the  urine  are  urates,  uric  acid,  phosphates,  and 
chlorides,  all  of  which  vary  much  under  normal  conditions  and 
II 


1 62  CARE  OF  INFANTS  AND  CHILDREN 

will  depend  largely  upon  the  amount  and  character  of  the  food 
ingested. 

Eighty  to  85  per  cent,  of  the  nitrogen  representing  the 
metabolism  of  albuminous  food  is  excreted  in  the  urine.  There 
is  also  a  considerable  difference  in  the  quantity  of  various  salts 
in  the  urine,  depending  on  whether  a  baby  is  breast-  or  bottle-fed. 

Bacteria  in  the  Urine. — Under  normal  conditions  urine  is 
practically  sterile  when  passed  and  contains  no  albumin  or  sugar. 
During  an  infectious  illness  great  numbers  of  bacteria  may  be 
passed  in  the  urine.  Certain  children  when  in  the  upright  posi- 
tion have  albumin  in  the  urine  without  any  inflammatory  condi- 


FlG.   80. — Apparatus  in  place  for  securing  specimen  of  urine. 

tion  of  the  kidneys  being  present.  This  condition  is  known  as 
orthostatic  albuminuria.  When  in  the  recumbent  position  the 
albumin  disappears.  Blood-cells  are  within  very  narrow  limits 
also  abnormal  in  the  urine,  and  if  found  in  any  numbers  always 
mean  some  inflammatory  condition  somewhere  along  the  urinary 
tract. 

A  urine  which  is  too  concentrated  as  a  result  of  excessive 
meat,  fruit  or  salt  in  the  diet,  may  cause  inflammation  and  severe 
irritation  without  any  infection  being  present. 

Deposits. — Whenever  the  urine  is  abnormal  in  color  or 
contains  an  abnormal  amount  of  deposit  of  any  kind,  a  specimen 
should  be  sent  to  the  physician  for  examination,  together  with 
all  the  symptoms  observed. 


THE  URINE  163 

Incontinence  OF  Urine 

Incontinence  of  urine  in  older  children  is  of  common  occur- 
rence, in  both  boys  and  girls. 

Many  children  who  control  their  bladders  perfectly  during 
the  day  wet  the  bed  at  night  and  without  knowing  that  anything 
has  happened.  Some  children  have  also  imperfect  control  dur- 
ing the  day,  and  unless  permitted  to  go  often  to  the  toilet  they 
will  usually  be  soiled. 

In  many  of  these  cases  there  is  simply  a  lack  of  control  of 
the  sphincter  muscle.  The  condition  is  always  exaggerated  by 
nervousness  and  fear  of  punishment,  while  encouragement  and 
reward  may  be  followed  by  good  results. 

A. specimen  of  urine  should  always  be  carefully  analyzed,  as 
some  of  these  cases  are  due  to  a  bladder  infection  or  to  urine 
which  is  too  concentrated  from  improper  diet.  An  excessive 
amount  of  certain  fruits,  such  as  oranges  or  grape-fruit,  may 
set  up  a  bladder  irritation,  causing  incontinence. 

When  no  local  condition  can  be  found  to  account  for  the 
incontinence,  the  child  must  be  taught  to  control  the  sphincter. 

The  child  may  be  required  to  stop  and  resume  urination 
several  times  during  the  emptying  of  the  bladder. 

The  amount  of  fluid  allowed  should  be  greatly  restricted 
during  the  latter  part  of  the  afternoon,  and  the  child  taken  up 
regularly,  at  the  parents'  bedtime,  and  again  during  the  night,  if 
necessary. 

Diseases  of  the  Urinary  Tract 

Etiology. — Infections  of  the  urinary  tract  are  very  common 
in  infants  and  young  children,  and  particularly  in  females.  The 
two  most  common  organisms  producing  these  infections  are  the 
colon  bacillus  and  the  gonococcus. 

The  character  of  the  female  genitals,  the  labia,  the  vagina, 
and  the  short  urethra,  the  opening  of  which  is  hidden  in  the 
folds  of  the  mucous  membrane,  makes  giirls  particularly  sus- 
ceptible to  infections,  as  compared  with  boys. 


l64        CARE  OF  INFANTS  AND  CHILDREN 

Colon  Bacillus. — Infections  involving  the  bladder,  and  not 
infrequently  the  pelvis  of  the  kidney,  or  even  the  kidney  itself, 
are  frequently  produced  by  the  colon  bacillus.  The  fact  that 
such  a  large  percentage  of  these  cases  occur  in  girls  suggests 
•soiling  from  the  stools  as  the  probable  source  of  infection  in 
most  cases. 

The  greatest  care  should,  therefore,  be  exercised  in  cleansing 
infants  when  they  are  soiled  with  the  stool,  so  that  none  of  the 
fecal  matter  comes  in  contact  with  the  urethra.  (See  care  of 
the  genitals.) 

Symptoms. — Babies  suffering  from  an  acute  pyelocystitis 
due  to  the  colon  bacillus  have  a  high  fever,  frequently  as  high 
as  105°,  which  may  persist  for  days  or  may  subside  in  a  few 
hours,  and  then  suddenly  recur.  The  condition  sometimes  as- 
sumes somewhat  the  character  of  typhoid ;  a  blood  and  urine 
examination,  however,  would  usually  differentiate  the  two. 
Where  there  is  an  involvement  of  the  bladder  there  is  great  rest- 
lessness and  frequent  micturition,  with  straining,  sometimes  only 
a  few  drops  being  passed  at  one  time.  The  mucous  membrane 
around  the  urethra  is  usually  inflamed.  The  urine  is  usually 
turbid  when  passed,  and  after  standing  for  a  few  minutes  if  it 
contains  pus  there  will  be  a  deposit.  In  many  cases  the  turbid 
character  is  due  to  myriads  of  colon  bacilli.  The  urine  is  usually 
acid  in  reaction. 

Microscopic  Examination. — When  such  an  infection  is 
suspected  a  specimen  should  be  obtained,  at  any  cost  of  time  or 
trouble,  and  examined  microscopically.  The  diet  should  be  of 
the  simplest  character,  milk  and  cereals  chiefly,  with  large 
amounts  of  water.  Sugar  and  salt  should  be  largely  eliminated 
from  the  diet.  In  certain  cases  a  catheterized  specimen  of  urine 
must  be  obtained,  to  determine  the  bacterial  count. 

When  the  temperature  is  high  and  there  is  great  restlessness, 
a  cool  sponge  or  pack  is  indicated.  When  there  is  excessive 
irritation  of  the  bladder  hot  fomentations  placed  over  the  bladder 
and  between  the  thighs  will  sometimes  give  marked  relief.  The 
character  of  the  medication  will  depend  upon  the  examination 


THE  URINE  165 

of  the  urine.  Rest  in  bed  with  large  quantities  of  water  by 
mouth  are  of  great  importance  in  the  treatment. 

GoNORRiUKA. — Gonorrhoeal  infection  of  the  genital  or  urinary 
tract  is  a  serious  condition  and  demands  the  most  careful  and 
intelligent  care. 

Every  discharge  from  the  urethra  or  vagina  in  a  child  should 
be  examined  microscopically.  A  smear  should  be  made  on  a 
glass  slide  and  submitted  to  the  physician  for  examination. 

In  hospitals,  where  several  children  occupy  a  ward,  all  new 
cases  should  be  first  isolated  until  smears  are  made  and  ex- 
amined. The  disease  has  a  remarkable  tendency  to  spread,  and 
too  great  care  cannot  be  taken  to  prevent  the  introduction  of  a 
case  into  the  wards. 

Isolation. — A  nurse  who  has  charge  of  a  gonorrhoea  case 
should  not  take  care  of  other  children.  Her  hands  should  be 
thoroughly  washed  after  each  dressing.  The  child  should  be 
isolated  and  all  diapers  and  clothing  washed  and  boiled.  The 
nurse  should  realize  the  danger  of  infection  to  herself  and 
should  be  especially  careful  not  to  infect  her  own  eyes.  When- 
ever irrigations  are  given  she  should  wear  large  glasses  or 
goggles  to  prevent  water  from  splashing  into  her  eyes. 

The  hands  of  the  baby  should  not  be  allowed  to  come  in 
contact  with  the  genitals,  as  an  infection  of  the  eyes  may  follow. 
Diapers  of  cheese-cloth  which  can  be  burned  are  more  practical 
than  those  which  have  to  be  washed. 

Rest  in  Bed. — A  child  suffering  from  a  gonorrhoeal  vaginitis 
or  urethritis  should  be  kept  in  bed  during  the  acute  stage  and 
the  medicine  instilled  into  the  vagina  frequently  with  a  medicine 
dropper  with  a  blunt  point.  To  do  this  most  successfully,  the 
child  should  be  placed  on  the  back  and  the  knees  drawn  well  up 
over  the  abdomen.  Plenty  of  water  by  mouth,  with  fairly  large 
doses  of  some  urinary  antiseptic,  such  as  hexamethylenamine 
(urotropin),  may  do  something  to  prevent  the  infection  from 
ascending  further  in  the  urinary  tract.  Under  certain  conditions 
irrigation=  of  the  urethra  and  bladder  may  be  necessary. 


CHAPTER  XVI II 

OPHTHALMIA  NEONATORUM  (GONORRHCEAL 
OPHTHALMIA) 

Ophthalmia  neonatorum  is  usually  due  to  the  gonococcus, 
although  it  may  occasionally  result  from  the  pneumococcus  or 
one  of  the  other  forms  of  pus  cocci.  The  infection  is  usually 
acquired  from  the  vaginal  discharges  of  the  mother  at  the  time 
of  birth. 

Blindness. — Gonorrhoeal  ophthalmia  is  responsible  for  a 
large  percentage  of  blindness.  According  to  Cohn,  31  per  cent, 
of  the  inmates  in  the  asylums  for  the  blind  in  Germany  are  a 
result  of  this  disease,  and  in  this  country,  according  -to  Lux,  the 
percentage  is  about  the  same. 

Means  of  Infection. — The  disease  may  also  be  acquired 
from  infected  dressings,  or  utensils,  or  from  the  hands  of  the 
physician  or  nurse.  The  disease  usually  manifests  itself  on  the 
second  or  third  day  after  birth.  In  the  great  majority  of  the 
cases  both  eyes  are  affected  from  the  first,  or  soon  become 
infected.  The  eyelids  become  more  and  more  oedematous,  so 
that  after  a  day  or  so  it  is  impossible  for  the  infant  to  open 
them.  The  discharge,  which  at  first  is  somewhat  serous  and 
flocculent,  soon  becomes  creamy  and  more  profuse,  so  that  the 
conjunctiva  is  constantly  bathed  in  pus. 

Duration. — Under  favorable  conditions  the  disease  lasts 
from  two  to  six  weeks. 

Prevention. — As  a  matter  of  prevention,  whenever  there  is 
the  least  suspicion  of  a  gonorrhoeal  infection,  the  eyes  should  be 
bathed  with  sterile  water  directly  after  birth  and  one  drop  of  a 
2  per  cent,  solution  of  silver  nitrate  dropped  into  each  eye. 
If  only  one  eye  is  affected,  the  other  should  be  sealed  up  with 
gutta-percha  tissue,  or  covered  with  oiled  silk.  It  should  be 
166 


OPHTHALMIA  NEONATORUM 


167 


watched  frequently,  and  in  case  of  possible  infection  heroic 
measures  should  be  taken  at  once. 

Treatment. — The  conjunctiva  should  be  kept  as  free  from 
secretion  as  possible  by  douching  every  half -hour,  or  every  hour, 
with  some  mild  antiseptic  solution.  Some  device,  such  as  an 
inverted  ear  speculum,  for  getting  the  solution  between  the  lids 
must  be  used.  The  eyelids  must  be  separated  in  order  to  get 
medication  within  them  and  to  wash  out  the  secretions  (Fig.  81). 


Fig.  81. — Method  of  separating  the  eyelids.     (Wick's  Disease  of  the  Eye, 
Lea&  Febiger.) 

In  order  to  do  this  a  small  piece  of  sterile  gauze  must  be  used 
under  the  fingers  in  order  to  make  traction  and  an  assistant 
will  usually  be  necessary,  if  effective  work  is  to  be  done.  Com- 
presses wrung  out  of  iced  water  should  be  laid  upon  the  eyes 
and  changed  every  few  minutes  if  the  discharge  is  profuse 
(Fig.  82). 

Once  or  twice  daily  the  conjunctiva  should  be  painted  over 
by  the  physician  with  a  2  per  cent,  solution  of  silver  nitrate. 


1 68 


CARE  OF  INFANTS  AND  CHILDREN 


OPHTHALMIA  NEONATORUM  169 

The  great  danger  in  these  cases  is  from  ulcer  of  the  cornea, 
which  frequently  perforates,  destroying  the  eye,  or  from  the 
formation  of  opacities  from  the  scar,  which  result  in  blindness. 

Microscopic  Examination  of  the  Discharge. — In  every 
case  when  there  is  any  discharge  from  the  eyes  a  smear  should 
be  taken  and  a  microscopic  examination  made  to  determine  its 
exact  character,  as  any  discharge  from  a  baby's  eye  should  be 
regarded  as  gonorrhoeal  until  proved  not  to  be.  In  no  case 
should  the  social  standing  of  the  family  preclude  this  precaution 
being  taken,  when  a  discharge  appears  in  the  eyes  of  the  new- 
born infant. 


CHAPTER  XIX 

DEFECTIVE  VISION,  ITS  CAUSES  AND 
SIGNIFICANCE 

Defects  of  vision  are  common  in  children  of  all  ages. 

These  defects  may  be  congenital  or  acquired.  Congenital 
defects  may  be  due  to  degenerative  changes  in  the  structure  of 
the  eye,  cornea,  lens,  retina,  or  optic  nerve,  or  to  simple  mal- 
formations in  the  shape  of  the  eye,  by  which  the  light  is  not 
properly  focused  on  the  retina.  Such  children  are  near-sighted 
(myopic),  far-sighted   (hyperopic),  or  astigmatic. 

Children  also  suffer  from  defective  muscle  control  of  one 
or  both  eyes,  in  which  case  the  eyes  do  not  properly  coordinate. 
When  the  incoordination  is  of  such  a  degree  that  the  axes  of 
the  eyes  are  distinctly  out  of  line,  the  condition  is  known  as 
strabismus,  cross-eyes,  or  squint.  Many  of  the  muscle  defects 
result  from  the  acute  infectious  diseases,  particularly  infantile 
paralysis  and  diphtheria. 

Defects  of  vision  are  frequently  due  to  opacities  of  the 
cornea,  resulting  from  gonorrhoeal  ulcers,  interstitial  keratitis 
due  to  syphilis,  inherited  or  acquired,  and,  among  certain  immi- 
grants, to  a  contagious  disease  known  as  trachoma  (granular 
lids),  which  produces  serious  opacities  of  the  cornea,  and  even 
blindness. 

Headache. — Many  of  the  errors  of  refraction  go  unrecog- 
nized until  children  reach  the  school  age,  and  many  times  only 
then  after  severe  symptoms,  such  as  headache  or  other  nervous 
symptoms,  have  appeared.  The  margins  of  the  lids  are  liable 
to  be  inflamed  and  in  the  morning  there  is  often  considerable 
secretion. 

School  Children  With  Refractive  Errors. — "  The  num- 
ber of  short-sighted  pupils  increases  from  the  lowest  to  the 
highest  schools,  and  the  increase  is  in  direct  proportion  to  the 
170 


DEFECTIVE  VISION 


171 


time  devoted  to  the  strain  of  school  life.  Forty-seven  per  cent, 
of  college  graduates  are  myopic.  Far-sightedness  passes  into 
near-sightedness  through  astigmatism  as  a  result  of  the  effort 
made  to  properly  focus  the  eyes." 

Necessity  for  Systematic  Examination  of  the  Eyes. — 
Every  child  before  entering  school  should,  therefore,  have  a 
systematic  examination  made,  by  an  oculist,  as  to  the  state  of 
its  vision,  and  if  found  sufficiently  defective,  proper  glasses 
should  be  adjusted.  Many  of  the  muscular  defects  may  be 
corrected  by  exercises  or  by  proper  surgical  measures. 

Eye-strain. — Eye-strain  often  results  from  improper  light- 
ing. The  light  may  be  insufficient  or  improperly  directed.  Bright 
lights  which  shine  directly  into  the  eyes  should  never  be  per- 
mitted. The  light  should  always  come  from  behind  and  over 
the  left  shoulder. 

Reading  at  Improper  Angles. — The  angle  at  which  the 
book  is  held  in  relation  to  the  eyes  is  of  the  greatest  importance. 
Children  should  never  be  allowed  to  read  while  lying  down,  as 
eye-strain  is  a  sure  result.  Heavy  books,  if  held,  are  almost 
certain  to  be  read  at  an  improper  angle  and  at  an  improper 
distance. 


CHAPTER  XX 

TETANUS 

Tetanus  Bacillus. — Tetanus  in  new-born  infants  (tetanus 
neonatorum)  is  usually  due  to  an  infection  through  the  umbilicus. 
The  disease  is  due  to  the  tetanus  bacillus.  This  organism  is  a 
constant  inhabitant  of  garden  earth  and  horse  manure.  Among 
the  poor,  and  especially  where  there  are  few  precautions  taken 
regarding  cleanliness,  tetanus  in  new-born  babies  is  not  uncom- 
mon. Osier  reports  that  in  some  of  the  West  Indian  islands 
more  than  half  of  the  mortality  among  the  native  children  was 
due  to  tetanus. 

Symptoms. — The  disease  is  characterized  by  tonic  contrac- 
tions of  the  muscles.  One  of  the  early  symptoms  is  the  difficulty 
in  nursing,  because  of  the  child's  inability  to  relax  the  muscles  of 
the  jaws  and  face.  The  muscular  contractions  become  more 
marked  and  more  general,  so  that  there  may  be  marked  retrac- 
tion of  the  head,  and  even  opisthotonos  (Fig.  109) .  The  muscles 
frequently  become  fixed  in  extreme  flexion.  The  child  often  dies 
from  fixation  of  the  muscles  of  respiration. 

Punctured  and  Lacerated  Wounds. — Tetanus  in  older 
children  usually  results  from  some  punctured  or  lacerated  wound, 
such  as  that  produced  by  stepping  on  a  nail  or  from  the 
explosion  of  a  toy  pistol  or  fire-cracker. 

All  such  wounds  should  be  thoroughly  cleansed  at  once,  the 
child  should  be  taken  to  a  physician,  and  if  the  wound  is  such 
that  it  is  impossible  to  thoroughly  irrigate  it  an  opening  suffi- 
ciently large  to  insure  proper  drainage  may  be  necessary.  Deep 
punctured  wounds  may  have  to  be  curetted  and  cauterized. 

Treatment. — When  a  wound  cannot  be  thoroughly  cleansed, 
or  when  some  time  has  elapsed  before  it  has  been  cleaned,  a 
dose  of  anti-tetanic  serum  should  be  given.  The  treatment  of 
172 


TETANUS  173 

well-developed  cases  calls  for  large  doses  of  serum,  both  sub- 
cutaneously  and  intraspinously.  An  absolutely  quiet  room  and 
as  little  handling  as  possible  are  essentials  in  the  treatment  of 
these  cases,  as  the  slightest  external  stimulus  is  often  sufficient 
to  produce  violent  tonic  convulsions. 

To  control  the  convulsions  it  may  be  necessary  to  give  strong 
sedatives  hypodermically,  such  as  chloral  or  morphine,  or  its 
derivatives,  and  inhalations  of  chloroform  may  be  a  temporary 
measure. 


CHAPTER  XXI 
CRETINISM  AND  MYXCEDEMA  IN  CHILDREN 

Etiology. — Cretinism  is  a  term  applied  to  infants  and  chil- 
dren who  from  a  very  early  age  have  shown  signs  of  insuffi- 
cient thyroid  secretion.  The  conditions  may  be  due  to  a  con- 
genital absence  of  the  thyroid  gland,  or  to  an  early  degeneration 
of  the  gland  structure,  resulting  in  insufficient  secretion. 

There  are  various  degrees  of  cretinism,  varying  from  slight 
insufficiency  with  its  corresponding  symptoms,  to  complete 
absence  of  the  gland. 

Symptoms. — The  symptoms  of  the  well-developed  cretin  are 
quite  characteristic  (Figs.  83,  84  and  85).  During  the  first  few 
months  there  may  be  little  to  suggest  the  cretin,  although  the 
infant  usually  does  not  grow  normally  and  is  not  responsive. 
This  has  been  explained  by  the  probability  that  through  the 
mother's  milk  ithe  infant  may  derive  a  certain  amount  of  thyroid 
secretion. 

The  following  is  a  clinical  picture  of  the  condition,  by 
A.  E.  Garrod: 

"  In  build,  the  child  is  stumpy  and  thick-set,  and  the  limbs 
are  short  in  comparison  to  the  trunk.  The  skin  is  harsh  and 
dry  and  has  a  yellowish,  sallow  tint,  whereas  the  extremities  are 
cold,  as  a  rule,  and  exhibit  a  distinct  cyanosis. 

"  The  hair  of  the  head  is  coarse,  brittle  and  scanty,  and 
usually  reddish-brown  in  color.  The  individual  hairs  seem  to 
be  set  too  widely  apart,  but  the  body  may  be  covered  in  parts, 
as  also  may  be  the  forehead,  with  a  coarse  dozvn.  The  fon- 
tanelle  remains  open  long  after  the  period  at  which  it  closes  in 
the  normal  child.  The  eruption  of  the  milk  teeth  is  usually, 
although  not  always,  delayed  and  these  teeth  persist  much  longer 
than  is  normal  and  permanent  teeth  are  correspondingly  delayed." 

The  facial  expression  is  characteristic.  The  eyes  are  nar- 
row and  set  far  apart.    The  nose  is  broad  and  flat.     The  lips 

174 


CRETINISM  AND  MYXCEDEMA 


175 


are  thick  and  the  tongue  usually  protruding  between  the  lips, 
as  if  too  large  for  the  mouth. 

The  abdomen  is  usually  large  and  the  umbilicus  protruding, 

Fig.  83. 


Fig.  84. 


I 

*  -J 

Fig.  y..^.  —  Typical  cretin,  two  and  one-half  years  old.    (Holt,  "  Diseases  of  Infancy  and 

Childhood,"  Appleton.) 

Fig.  84. — Typical  cretin.  (Holt,  "Diseases  of  Infancy  and  Childhood,"  Appleton.) 


from  the  presence  of  umbilical  hernia.  The  fingers  are  short 
and  stumpy. 

The  mental  development  is  as  backward  as  the  physical,  and 
when  six  or  eight  years  old  the  mentality  is  often  that  of  a  child 
of  one  year  or  less. 

"  The  disposition  is  usually  placid  and  apathetic."  There  are 
lacking  the  spasmodic  fits  of  anger  so  common  in  the  other  forms 
of  the  mentally  defective. 


176 


CARE  OF  INFANTS  AND  CHILDREN 


TRiiATMi-:NT. — The  treatment  consists  in  supplying  the  proper 
amount  of  thyroid  secretion.  This  is  usually  derived  from  the 
thyroid  gland  of  the  sheep  and  given  in  tablet  form.  An  ex- 
cessive amount  may  produce  symptoms  of  hyperthyroidism  which 


FiG.Ss. — After  six  months'  treatment  with  thyroid  extract.   (Holt,  "Diseases  of  Infancy 
and  Childhood,"  Appleton.) 

are  not  unlike  those  of  exophthalmic  goitre/  i.e.,   rapid  and 
irregular  heart  and  muscular  tremor. 

If  a  diagnosis  is  made  sufficiently  early  and  treatment  begun 
and  persisted  in,  these  cases  may  develop  almost  normally.  In 
case  of  long  standing,  the  results  of  treatment  will  be  corre- 
spondingly  unsatisfactory. 

'  For  hyperthyroidism  and  exophthalmic  goitre,  see  a  treatise  on  gen- 
eral medicine. 


CHAPTER  XXII 

CONGENITAL  DEFORMITIES:  CLUB-FOOT— CON- 
GENITAL DISLOCATION  OF  THE  HIP— MAL- 
FORMATIONS OF  THE  LIPS,  TONGUE,  AND 
PALATE 

Club-foot 
There  are  four  simple  forms  of  club-foot  or  talipes  de- 
scribed, namely: 

1.  Talipes  equinus,  a  condition  in  which  the  foot  is  extended, 
the  heel  being  drawn  up.  In  this  position  the  patient  walks  upon 
the  ends  of  the  heads  of  the  metatarsal  bones,  an  attitude  that 
suggested  the  name  equinus   (horse-like). 

2.  Talipes  calcaneus,  the  dorsi-flexed  foot,  in  which  the  pa- 
tient walks  on  the  heel. 

3.  Talipes  varus,  a  condition  in  which  the  foot  is  inverted. 

4.  Talipes  valgus,  a  condition  in  which  the  foot  is  everted. 
The  most  common  form  is  a  combination  of  two  of  these 

forms  known  as  talipes  equinovarus,  in  which  the  foot  is  ex- 
tended and  at  the  same  time  turned  in.  The  talipes  equinovarus 
forms  77.4  per  cent,  of  the  total  number  of  club-foot  occurring 
in  infants.  This  form  is  illustrated  by  the  accompanying  plates 
(Figs.  86  and  87). 

The  disease  may  be  congenital  or  acquired.  Many  of  the 
acquired  cases  result  from  contractions  of  the  muscles  due  to 
infantile  paralysis    (anterior  poliomyelitis). 

It  is  apparent  that  the  longer  the  bones  remain  in  incorrect 
relative  positions  to  each  other,  the  more  exaggerated  will  the 
deformities  become  and  the  less  chance  there  will  be  of  securing 
proper  correction.  To  this  end  infants  with  club-foot  should 
be  taken  at  once  to  an  orthopedic  surgeon  where  proper  treat- 
ment in  the  way  of  reduction  and  the  application  of  plaster  casts 
may  be  begun. 

12  177 


CARE  OF  INFANTS  AND  CHILDREN 


Fig.  86. 


Fig.  87. 


Fig.  86. — Club-foot  in  boy  of  seven  years. 

Fig.  87. — Same  case  after  one  year's  treatment.    (Minnesota  State  Hospital  for  Crippled 

and  Deformed  Children.) 


When  treatment  in  these  ca.ses  is  begun  early  and  properly 
persisted  in,  many  of  them  develop  almost  normally,  so  that 
after  a  few  years  practically  no  deformity  is  apparent. 


CONGENITAL  DEFORMITIES 


179 


Congenital  Dislocation  of  the  Hip 

The  dislocation  may  be  single  or  double. 

After  the  child  begins  to  walk,  there  should  be  no  special 
difficulty  in  recognizing  that  there  is  something  wrong.  The 
child  should  be  taken  to  a  physician  for  examination. 

By  proper  manipulation  by  a  skilled  orthopedist,  these  dis- 
locations may  frequently  be  reduced  and 
held    in    place,    until    nature    develops    a 
joint. 

The  accompanying  illustration  (Fig. 
88)  shows  the  degree  of  deformity  which 
may  result  in  allowing  these  cases  to  go 
untreated. 

Malformations  of  the  Lips,  Tongue, 

AND  Palate 

hare-lip  and  cleft  palate 

These  are  among  the  most  frequent 
congenital  deformities.  Hare-lip  may  be 
either  single  or  double.  The  fissure  may 
vary  from  a  slight  notch  in  the  lip  to  a 
complete  division,  extending  on  one  or 
both  sides  to  and  including  the  floor  of 
the  nose  (Fig.  89).  Frequently  accom- 
panying a  hare-lip  there  is  a  wide  gap  in 
the  roof  of  the  mouth. 

Surgical  Treatment.  —  The  treat- 
ment of  these  cases  is  surgical,  the  time 
for  operation  being  usually  postponed  until 
the  infant  is  at  least  several  months  old. 
Not  infrequently  the  operation  for  closure  of  the  lip  and  palate 
may  require  more  than  one  operation.  Inability  to  nurse  may 
force  the  surgeon  to  operate  early. 

Feeding. — The  feeding  is  often  a  difficult  problem.  If  there 
is  any  considerable  separation  of  the  lip  or  palate,  the  baby  will 
be  unable  to  nurse  or  take  milk  from  a  nipple.     It  will  usually 


Fig.  88. — Congenital  dis- 
location of  the  hip  (un- 
treated). (Minnesota  Hos- 
pital for  Crippled  and  De- 
formed Children.) 


i8o  CARE  OF  INFANTS  AND  CHILDREN 

Fig.  89. 

■        ^- 


"^ 


Fig.  90. 

Pig.  89. — Double  hare-lip  and  cleft  palate.    (Courtesy  of  Dr.  W.  A.  Dennis.) 
Fig.  90. — Same  case  one  year  after  operation. 


CONGENITAL  DEFORMITIES  l8l 

be  necessary  to  feed  it  with  a  spoon  or  dropper.  A  modified 
Breck  feeder  (see  Fig.  47),  made  larger  than  for  premature 
infants,  can  be  used  lo  great  advantage. 

Many  of  these  cases  die  of  starvation  because  they  get 
insufficient  food. 

Breast  Milk. — The  breast  milk  should  be  maintained  by 
pumping  or  by  expression  and  given  the  baby  as  described  above, 
or  where  the  mother  has  insufficient  milk,  breast  milk  may  fre- 
quently be  secured  from  other  sources.  A  thin  plate  of  rubber 
may  sometimes  be  successfully  used  during  nursing,  to  close  the 
cleft,  when  it  is  not  too  wide. 

Although  some  of  the  cases  present  a  hideous  appearance, 
the  modem  plastic  surgeon  can  usually  transform  them  into 
normal  looking  individuals  (Fig.  90). 

TONGUE-TIE 

This  deformity  is  not  nearly  so  frequent  as  most  people  sup- 
pose. If  the  tongue  can  be  protruded  beyond  the  lips,  it  is  not 
of  sufficient  gravity  to  warrant  an  operation.  If,  however,  the 
frcenum  is  so  short  as  to  interfere  with  the  baby's  nursing,  or 
later  with  its  articulation,  it  should  be  cut  with  a  dull  scissors 
and  by  blunt  dissection.  Whenever  there  is  any  possible  history 
of  bleeding  in  the  family  the .  operation  should  never  be  done 
under  ^any  circumstances. 


CPIAPTER  XXIII 
ENLARGEMENT  OF  THE  BREASTS  IN  INFANTS 

Enlargement  of  the  breasts  in  young  infants  is  of  rather 
common  occurrence.  Combined  with  this  enlargement  is  a 
secretion  of  fluid  which  closely  resembles  colostrum  or  milk. 
The  amount  of  this  fluid  which  can  be  expressed  is  from  a 
few  drops  to  one-half  teaspoonful.  This  milk,  which  was  sup- 
posed in  olden  times  to  have  some  supernatural  origin,  was 
called  "  witch's  milk." 

The  condition  has  no  particular  significance,  and  if  let  alone 
it  will  usually  disappear  in  a  couple  of  weeks.  If,  however,  the 
breasts  are  rubbed  and  squeezed,  serious  trauma  may  result, 
producing  considerable  swelling,  and  even  abscess  formation, 
the  infectious  organisms  entering  probably  by  way  of  the  ducts. 

Treatment. — When  enlargement  of  the  breasts  occurs,  even 
when  there  is  a  secretion  of  milk  from  the  ducts,  nothing  more 
than  simple  cleanliness  is  necessary.  If  there  is  evidence  of 
inflammation  and  abscess  formation,  the  physician  should  be 
notified,  as  it  may  be  necessary  to  evacuate  the  pus. 


182 


CHAPTER  XXIV 

AFFECTIONS  OF  THE  DIGESTIVE  TRACT 

Inflammation  of  the  Mucous  Membrane  of  the  Mouth 

(Stomatitis) 

There  are  several  forms  of  stomatitis  common  to  infants. 
These  are :  catarrhal  stomatitis  ;  herpetic,  or  aphthous  stomatitis  ; 
thrush ;  sprue ;  soor ;  ulcerative  stomatitis  and  gangrenous 
stomatitis. 

Catarrhal  Stomatitis. — This  condition  is  common  in  in- 
fants, particularly  in  those  artificially  fed.  It  may  occur  from 
hard  or  rough  nipples,  comforts,  from  swabbing  the  mouth,  and 
during  many  of  the  infectious  diseases,  such  as  typhoid  fever 
and  scarlet  fever. 

The  condition  is  characterized  by  redness  and  swelling  of 
the  mucous  membrane.  There  is  undoubtedly  marked  tender- 
ness to  pressure,  and  as  a  result  the  baby  is  fretful,  drools  a 
great  deal,  and  shows  a  marked  disinclination  to  take  food. 
There  may  be  slight  fever. 

Treatment. — All  irritation  should  be  removed ;  the  food 
should  be  given  for  a  few  days  by  means  of  a  spoon,  or  modified 
Breck  feeder.  The  mouth  may  be  washed  or  swabbed  after 
each  feeding  with  some  mild  alkaline  and  antiseptic  solution, 
such  as  Seiler's  solution. 

Aphthous  of  follicular  stomatitis  is  characterized  by 
the  appearance  of  small  blisters  scattered  over  the  tongue  and 
cheeks.  In  the  latter  form  the  superficial  ulcers  are  very  pain- 
ful. The  same  treatment  as  for  the  catarrhal  form  may  be 
used,  except  that  the  small  ulcers  may  have  to  be  touched  with 
silver  nitrate. 

Thrush  or  sprue  is  a  common  affection  in  nursing  babies. 
It  ^appears  as  white  flakes  which  resemble  small  milk  curds, 
scattered  over  the  mucous  membrane  of  the  mouth.     It  is  made 

183 


l84  CARE  OF  INFANTS  AND  CHILDREN 

up  chiefly  of  an  exudate  of  fibrin.  If  these  spots  are  wiped 
oflf,  bleeding  points  are  left,  showing  that  there  has  been  some 
superficial  destruction  of  the  mucous  membrane.  The  condition 
is  due  to  the  growth  in  the  mouth  of  a  fungus  called  saccharo- 
myces  albicans. 

All  irritation  should  be  removed  and  the  mouth  washed — 
not  swabbed — after  each  nursing  with  a  mild  antiseptic.  Thrush 
grows  more  rapidly  on  an  acid  medium;  therefore,  in  the  treat- 
ment an  alkaline  solution  should  always  be  used.  The  condition 
disappears  more  quickly  in  artificially-fed  infants  if  the  sugar  is 
omitted  for  a  time. 

Ulcerative  stomatitis  usually  occurs  in  older  children, 
beginning  around  the  margins  of  the  gums  and  producing  more 
or  less  destruction  of  the  mucous  membrane.  There  may  be 
marked  involvement  of  the  adjacent  glands  as  a  result  of  ab- 
sorption of  the  infection  by  the  lymphatics. 

The  condition  occurs  usually  in  children  with  bad  teeth,  or 
in  those  with  lowered  vitality.  Severe  ulceration  of  the  mucous 
membrane  may  follow  or  complicate  the  infectious  diseases. 
Ulcerative  stomatitis  due  to  syphilis  is,  of  course,  common. 

Gangrenous  stomatitis  or  noma — an  extreme  condition, 
in  which  a  large  portion  of  the  cheek  may  be  eaten  away — 
may  sometimes  follow  the  infectious  diseases,  particularly 
measles  or  scarlet  fever.  The  disease  is  very  fatal,  at  least  two- 
thirds  of  the  cases  succumbing.  The  treatment  is  largely  sur- 
gical and  consists  of  curettage  and  cauterization  of  the  tissues 
beyond  the  gangrenous  area. 

The  maintenance  of  the  vitality  by  proper  food  in  these  cases 
is  of  the  greatest  importance,  as  the  chance  of  recovery  depends 
upon  the  strength  of  the  tissues  to  resist  further  invasion. 

Tonsillitis  and  Ph.xryngitis 
The  tonsils  are  masses  of  lymphoid  tissue  situated  between 
the  pillars  of  the  fauces,  and  when  normal  in  size  they  do  not 
project  beyond  the  margins  of  the  pillars.     There  is,  however. 


AFFECTIONS  OF  THE  DIGESTIVE  TRACT  185 

a  great  difference  in  the  size  of  the  tonsils  in  otherwise  healthy 
individuals,  so  that  within  certain  limits  the  size  in  itself  is  not 
a  safe  index  as  to  their  pathology.  Many  children  have  large 
tonsils  from  birth  but  without  any  symptoms.  The  exact  func- 
tion of  the  tonsils  is  yet  undecided.  It  is  possible,  however,  that  , 
they  are  really  lymph-glands  and  serve  normally  to  arrest  in- 
fection arising  in  the  mucous  membrane  of  the  mouth.  There 
is  little  doubt  that  infections  about  the  teeth  have  much  to  do 
in  producing  enlargement  and  even  abscess  of  the  tonsils. 

Varieties. — There  are  various  forms  of  tonsillitis^  the  most 
common  of  which  is  the  simple  catarrhal  form  in  which  the 
tonsils  are  somewhat  swollen  and  reddened.  There  may  be 
slight  fever  and  pain  upon  swallowing. 

The  next  most  common  form  is  what  is  generally  called 
follicular  tonsillitis.  The  tonsils  are  swollen  and  inflamed,  and 
each  crypt  in  the  surface  of  the  tonsil  is  filled  with  a  plug  of 
whitish  exudate. 

There  is  usually  marked  systemic  disturbance,  beginning  with 
a  chill,  high  temperature,  and  a  feeling  of  general  malaise. 
There  is  usually  considerable  pain  on  swallowing,  and  the  cer- 
vical glands  at  the  angle  of  the  jaw  are  usually  enlarged  and 
tender  to  pressure. 

Membranous  Tonsillitis  {Pseudo diphtheria). — This  form  of 
tonsillitis  is  characterized  by  a  more  or  less  diffuse  membrane 
which  covers  the  tonsils,  and  many  times  the  pillars  of  the 
fauces  and  the  uvula  as  well.  The  inflammation  is  usually  due 
either  to  the  streptococcus  or  to  the  bacillus  of  Vincent,  dis- 
covered by  him  in  1896.  The  disease  is  differentiated  from 
diphtheria  by  a  microscopic  examination. 

Symptoms.-— There  is  usually  a  marked  systemic  poisoning 
from  tonsillitis,  with  a  tendency  to  involvement  of  the  heart 
and  joints.  All  cases  of  tonsillitis  where  there  is  membrane 
should  have  smears  or  cultures  made,  as  there  are  many  cases 
which  cannot  be  otherwise  differentiated  from  diphtheria.  Al)- 
scess  of  the  tonsil  (quinsy)  frequently  follows  an  acute  attack 


l86  CARE  OF  INFANTS  AND  CHILDREN 

of  one  of  the  foregoing  forms  and  requires  surgical  inter- 
ference if  it  does  not  open  itself  within  a  reasonable  time. 

Rest  in  bed  should  be  insisted  upon  for  several  days  on 
account  of  possible  involvement  of  the  heart.  Local  applica- 
tion of  tincture  of  iodine,  2  to  5  per  cent.,  of  nitrate  of  silver, 
2  to  5  per  cent.,  as  well  as  gargling  with  some  antiseptic  solution, 
such  as  Seiler's,  may  be  of  benefit. 

Removal  of  the  Tonsils. — The  question  of  removal  of 
the  tonsils  is  one  which  is  now  receiving  much  consideration 
and  discussion  by  the  medical  profession.  That  there  are  many 
tonsils  which  should  be  removed  there  is  not  the  least  doubt. 
On  the  other  hand,  simply  because  tonsils  are  larger  than  normal 
is  not  sufficient  ground  for  their  removal. 

If  a  child  has  repeated  attacks  of  tonsillitis,  or  if  after  one 
attack  the  tonsils  are  evidently  the  seat  of  pus  pockets,  the 
tonsils  should  be  removed. 

Prevention. — If  the  teeth  are  kept  healthy  and  clean  by  a 
thorough  brushing  at  least  once  daily,  and  the  mouth  and 
throat  cleansed  of  particles  of  food  by  gargling  with  some 
simple  alkaline  solution,  such  as  Sejler's,  infections  of  the  tonsils 
would  be  much  less  frequent  than  they  are  now,  and  the  re- 
moval of  tonsils  would  be  less  often  necessary.  Pharyngitis 
usually  accompanies  tonsillitis,  although  a  pharyngitis  may  be 
present  without  any  special  involvement  of  the  tonsils. 

Retropharyngeal  abscess  is  not  unknown  in  infants  and 
is  a  dangerous  condition.  It  may  occur  independently  of  a 
tonsillitis  and  is  usually  attended  by  difficulty  in  swallowing  and 
later  in  breathing.  Such  an  accumulation  of  pus  should  be 
evacuated  at  once,  as  it  may  otherwise  be  followed  by  serious 
if  not  fatal  results. 

Affections  of  the  (Esophagus 
Congenital   malformations   of   the   oesophagus   occasionally 
occur.     The  most  common  forms  are  those  in  which  the  upper 
half  of  the  tube  ends  in  a  cul  de  sac  and  the  lower  half  opens 
into  the  trachea. 


AFFECTIONS  OF  THE  DIGESTIVE  TRACT  187 

In  some  cases  there  is  a  membrane  in  the  form  of  a  dia- 
phragm, which  stretches  across  the  lumen  of  the  tube.  These 
conditions  are  incompatible  with  life  and  the  infants  soon  die 
of  starvation,  the  position  of  the  obstruction  usually  making 
surgical  interference  impossible. 

In  diphtheria,  an  extension  of  this  membrane  into  the  oesoph- 
agus may  occur. 

Strictures. — Strictures  of  the  oesophagus,  due  to  the  swal- 
lowing of  corrosive  substances,  such  as  lye,  are  not  very  uncom- 
mon in  children.  Strictures  due  to  syphilitic  ulcers  may  also 
occur. 

Impaction  of  foreign  bodies  in  the  oesophagus  not  infre- 
quently occurs  in  infants  and  children,  producing  complete  or 
partial  obstruction. 

The  regurgitation  of  food,  almost  immediately  after  it  has 
been  taken,  the  food  showing  no  evidence  of  gastric  secretion, 
is  always  suggestive  of  oesophageal  obstruction.^  The  passing 
of  a  tube  will  usually  determine  whether  an  obstruction  is 
present,  and  its  location.  The  location  of  a  foreign  body,  such 
as  a  coin  or  button,  may  usually  be  determined  by  an  X-ray 
examination.  When  such  obstruction  is  suspected  the  child 
should  be  taken  at  once  to  a  physician. 

Malformations  of  the  Intestine 

The  most  common  malformation  is  an  atresia  of  the  rectum 
or  anus.  Where  the  obstruction  consists  only  of  a  septum  at 
or  near  the  anus,  the  condition  may  frequently  be  relieved  by 
surgical  means.  If,  however,  4;he  obstruction  is  higher  up  and 
there  is  a  considerable  length  in  which  the  tube  is  lacking,  there 
is  little  to  be  done  and  the  infant  rapidly  succumbs. 

There  is  another  malformation  of  the  large  bowel  which  is 
rather  rare  and  which  is  not  entirely  incompatible  with  life.  It 
is  known  as  Hirschsprung's  disease,  and  consists  of  a  con- 
genital dilation  of  the  colon.     The  natural  muscular  power  of 

'  When  free  hydrorhlnric  acid  is  present  Congo  paper  is  turned  blue. 


l88  CARE  OF  INFANTS  AND  CHILDREN 

the  colon  is  lacking  and  masses  of  fecal  matter  collect  in  the 
dilated  portion  and  have  to  l)c  removed  regularly  by  irrigation. 

DiAKUIKKA   AND   INTOXICATION 

The  term  diarrhoea  is  used  to  cover  all  conditions  in  which 
there  are  frequent,  loose  movements  of  the  bowels. 

Diarrhoea  may  result  from  a  great  variety  of  causes,  but  if 
persistent  it  must  always  be  considered  as  a  serious  condition 
in  infants.         , 

Mortality  p'Rom  Diarrikeal  Affections. — The  mortality 
in  children  of  all  ages  from  the  various  contagious  diseases  in 
New  York  City  during  the  years  1900  to  1904  was  23,330.  Dur- 
ing the  same  time  the  mortality  in  infants  under  two  years  of 
age,  due  to  diarrhoeal  affections,  was  26,563   (Holt). 

Owing  to  the  lack  of  resistance  of  young  infants  and  the 
delicate  character  of  the  intestinal  mucous  membrane,  they  are 
particularly  susceptible  to  over-feeding,  irritating  substances  in 
the  food,  and  to  infections. 

Artificially-fed  children  are  particularly  liable  to  diarrhoea, 
and  especially  during  the  hot  weather  or  during  sudden  and 
extreme  changes  in  the  weather. 

Over-feeding. — The  effects  of  over-feeding  with  cow's 
milk,  or  the  patent  foods,  frequently  result  during  the  hot 
weather  in  a  condition  of  intoxication,  which  is  usually  accom- 
panied by  fever,  frequent  watery  stools,  and  great  prostration. 

Some  of  these  cases  of  severe  diarrhoea  are  undoubtedly 
due  primarily  to  infected  milk,  but  many  of  them  are  due  to 
over-feeding  with  secondary  putrefactive  changes  due  to  various 
organisms. 

Diarrhoea  in  breast-fed  infants  is  almost  always  due  to  over- 
feeding, or  to  purgatives  which  the  mother  is  taking,  being 
eliminated  in  the  milk. 

Diarrhoea  in  bottle-fed  babies  is  frequently  due  to  a  milk 
too  rich  in  cream,  the  stools  being  usually  curdy  and  green  in 
character. 

Excessive  Fat  or  Sugar. — An  excessive  amount  of  sugar 


AFFECTIONS  OF  THE  DIGESTIVE  TRACT  189 

or  starch  in  the  food  will  also  produce  diarrhoea,  the  stools  being 
greenish  and  acid  in  character.  Such  discharges  usually  result 
in  marked  irritation  of  the  skin  about  the  rectum. 

In  cases  of  acute  intoxication,  where  the  movements  are  very 
frequent,  the  sudden  loss  in  tissue  fluids  rapidly  reduces  the 
vitality.  The  heart  is  rapid  and  weak  and  the  respirations  slow 
and  irregular.  The  tissues  are  shrunken,  the  skin  dry  and 
parchment-like,  the  eyes  hollow  and  expressionless,  and  the 
child  may  be  in  a  condition  of  collapse. 

Under  all  conditions,  whenever  a  diarrlura  begins,  all  food 
should  be  stopped  at  once,  and  only  ivater  given  for  a  few  feed- 
ings. The  giving  of  daily  doses  of  castor  oil,  or  other  purga- 
tives, in  diarrhoea  should  be  prohibited.  One  initial  dose  may 
be  given,  but  after  that  its  use  does  real  harm.  In  cases  where 
there  is  great  loss  of  tissue  fluids,  hypodermoclysis  of  normal 
salt  solution  may  be  necessary.  Colon  flushings  should  be  used 
only  under  a  physician's  directions,  as  they  frequently  do  more 
harm  than  good. 

The  greatest  care  should  be  exercised  in  getting  pure  milk, 
and  all  milk  should  be  boiled  or  properly  pasteurized. 

During  hot  weather  even  in  health  it  is  always  well  to  cut 
down  the  daily  quantity  of  milk,  and  particularly  the  cream. 

After  a  child  has  had  diarrhoea  it  is  often  necessary  to  give  a 
fat-free  diet  for  a  time.  Buttermilk,  albumin  milk,  or  malt  soup 
are  here  indicated.  These,  for  a  time,  may  have  to  be  given 
much  diluted  with  water. 

Never  encourage  parents  to  consider  the  teeth  as  a  cause 
of  diarrhoea.  If  the  cutting  of  teeth  produced  diarrhoea,  a  child 
would  have  diarrhoea  constantly  during  the  first  two  and  one- 
half  years  of  its  life,  since  the  baby  is  constantly  in  the  process 
of  getting  teeth  during  that  entire  time. 

ArPENDICITIS 

Appendicitis  in  young  infants  is  undoubtedly  rare.  In  chil- 
dren after  the  second  or  third  year,  it  is  rather  common.  The 
condition  is  often  not  recognized  until  after  the  attack  is  over. 


I90  CARE  OF  INFANTS  AND  CHILDREN 

when  a  tumor  may  often  be  felt  in  the  region  of  the  caecum.  I 
have  seen  it  frequently  happen  in  public  clinics  that  a  child 
would  be  brought  it,  with  a  history  of  having  been  ill  a  week 
or  two  previously,  with  fever,  vomiting,  and  colic,  and  upon 
examination  a  mass  of  variable  size  would  be  found  in  the 
region  of  the  appendix. 

After  the  diagnosis  has  been  well  established  it  is  well  to 
have  the  appendix  removed  during  the  period  between  the 
attacks. 

During  an  attack  of  appendicitis,  or  where  there  is  any 
probability  of  the  attack  being  appendicitis,  the  child  should  be 
kept  in  bed  and  all  food  withheld  for  24  or  36  hours,  with  the 
exception  of  teaspoonful  doses  of  water  or  broth.  No  cathartic 
should  be  given.  The  lower  bowel  may  be  emptied  by  a  simple 
enema.  A  physician  should  always  be  sent  for  and  the  symptoms 
carefully  watched,  as  surgical  intervention  may  be  necessary 
at  any  time. 

Intussusception 

An  invagination,  or  telescoping,  of  one  portion  of  the  intes- 
tine into  another  is  called  intussusception.  It  may  occur  in  any 
portion  of  the  intestines,  but  is  most  common  in  the  region  of 
the  caecum  and  along  the  colon. 

The  greatest  number  of  cases  occur  in  infants  between  the 
fourth  and  twelfth  month. 

The  condition  is  almost  always  fatal  if  not  promptly  recog- 
nized and  subjected  to  proper  surgical  treatment. 

The  first  symptoms  are  pain  and  vomiting.  The  pain  is  of 
a  colicky  intermittent  character.  The  vomitus  is  first  the  con- 
tents of  the  stomach  and  later  bile  and  mucus.  There  are 
usually  one  or  two  fairly  normal  stools,  after  which  they  con- 
sist largely  of  blood-stained  mucus,  or  often  of  bright  red  blood. 
Frequently  there  is  a  mass  which  can  be  felt  in  the  region  of 
the  caecum.  Whenever  such  symptoms  present  themselves,  a 
surgeon  should  be  summoned  at  once,  or,  better,  the  child  should 
be  taken  to  a  hospital  and  arrangements  made  for  immediate 
operation,  if  the  surgeon  decides  (the  condition  to  be  intussus- 


AFFECTIONS  OF  THE  DIGESTIVE  TRACT  191 

ception.  After  the  operation  these  cases  can  usually  begin  to 
have  some  food  after  a  brief  period,  diluted  breast  milk  being 
the   food  par  excellence. 

Prolapse  of  the  Rectum 

Prolapse  of  the  rectum  occurs  usually  in  children  after  the 
second  year  and  particularly  in  those  where  the  strength  of  the 
levator  ani  muscles  has  been  greatly  reduced.  Such  conditions 
as  simple  atrophy,  marasmus,  predispose  to  the  condition. 

During  the  straining  which  is  necessary  to  move  the  bowels 
the  mucous  membrane  protrudes  a  variable  distance.  In  the 
mild  cases  there  is  simply  a  fold  of  mucous  membrane  surround- 
ing the  anus,  while  in  the  more  severe  cases  the  whole  thickness 
of  the  bowel  is  prolapsed,  or  there  may  be  a  certain  amount  of 
invagination.  The  mucous  membrane  is  of  a  deep  purplish 
color  and  bleeds  easily  (Fig.  91). 

Should  these  children  suffer  from  any  inflammatory  con- 
dition of  the  colon  which  results  in  frequent  bowel  movements, 
attended  by  straining,  the  prolapse  will  naturally  be  much 
exaggerated. 

Treatment. — After  each  prolapse  the  bowel  should  be  care- 
fully replaced  by  gentle  traction  or  pressure.  The  use  of  olive 
oil  or  vaseline  wilj  assist  materially  in  replacing  the  prolapsed 
folds  of  the  mucous  membrane.  In  extreme  cases  it  may  be 
necessary  to  use  iced  applications,  at  the  same  time  placing  the 
child  on  the  face  with  the  head  lowered  and  the  pelvis  high. 
The  round  end  of  a  sofa  will  serve  this  purpose  well.  After  the 
tumor  is  reduced  it  should  not  be  permitted  to  protrude  again  if 
it  is  possible  to  prevent  it. 

The  lower  bowel  should  be  emptied  once  daily,  preferably 
at  night,  by  means  of  a  simple  enema  of  normal  salt  solution. 
It  should  be  introduced  slowly  and  retained  for  15  or  20  minutes. 
Too  much  fluid  should  not  be  given,  or  it  will  be  rejected  at 
once.  Half  a  pint  will  usually  be  sufficient.  The  child  should 
be  put  in  the  recumbent  position  during  the  enema  and  the 
bowels  should  be  allowed  to  move  in  that  position,  but  without 


192 


CARE  OF  INFANTS  AND  CHILDREN 


straining.  The  buttocks  may  be  pressed  together  to  prevent 
the  bowel  from  coming  down.  If  the  child  is  allowed  to  sit 
on  the  chamber,  so  that  it  can  bring  its  muscles  to  bear,  it  will 
almost  surely  force  the  mucous  membrane  out.  When  there  is 
present  a  colitis  and  much  straining,  supix>sitories  of  some  opiate 


Fig.   91. — Prolapse  of  rectum. 

may  be  necessary.     A   strip  of  surgeon's  plaster  holding  the 
buttocks  together  will  sometimes  be  useful. 

The  tendency  to  prolapse  becomes  less  marked  as  the  gen- 
eral health  of  the  individual  improves,  and  finally  disappears.  In 
rare  cases  surgical  intervention  may  be  necessary. 

Intestinal  Parasites 
In  children  intestinal  worms  are  much  less  common  than 
is  generally  supposed.  In  certain  parts  of  Europe  where 
meat  is  eaten  frequently  uncooked,  intestinal  parasites  are 
much  more  common.  The  prevalent  idea  among  the  laity  that 
a  child  has  worms  because  it  picks  its  nose,  grinds  its  teeth,  or 
is  restless  in  its  sleep,  is  entirely  erroneous.     Children  do  pick 


AFFECTIONS  OF  THE  DIGESTIVE  TRACT  193 

theit*  noses  and  grind  their  teeth  when  they  have  worms,  but 
they  also  do  the  same  thing  with  many  other  affections,  and 
especially  when  they  are  suffering  from  indigestion.  A  positive 
diagnosis  of  worms  should  be  established,  therefore,  before  any 
medication  is  given  for  their  eradication.  There  is  no  doubt 
that  many  children  are  seriously  poisoned  by  worm  remedies, 
when  usually  there  are  no  worms  present. 

Microscopic  Examination  of  Stools. — Intestinal  worms, 
if  present,  are  always  passed  from  time  to  time  in  the  stools, 
where  they  may  be  recovered,  or,  if  worms  are  suspected  and 
have  not  been  seen,  a  microscopic  examination  of  the  stool  will 
reveal  the  presence  of  the  eggs. 

The  three  common  varieties  of  intestinal  worms  which  are 
found  in  children  in  this  country  are:  (i)  Tapeworm  {Tcenia 
saginata — ^beef  tapeworm;  Tcenia  solium — pork  tapeworrn^; 
(2)  Ascaris  lumbricoides — round  worms;  (3)  Oxyuris  veVnii- 
cnlaris — pin-worm,  thread-worm. 

TAPEWORM 

The  beef  tapeworm  is  the  most  frequent  form  found  in 
children  in  this  country.  It  gains  access  to  the  intestinal  tract 
by  the  eating  of  raw  or  partially  cooked  beef  which  contains 
the  larvae.  The  larvae  develop  into  mature  worms  in  the  in- 
testines in  about  three  months.  From  time  to  time  the  mature 
segments  are  cast  off  and  appear  in  the  stools  (Fig.  92).  The 
worm  is  from  ten  to  twenty  feet  in  length.  The  mature  seg- 
ments are  from  one-half  to  three-quarters  of  an  inch  long,  and 
about  half  that  wide. 

Pork  tapeworm  is  a  rare  form  in  this  country.  It  comes 
from  eating  raw  pork  containing  the  larvae.  It  is  from  five  to 
ten  feet  long  and  the  mature  segments  are  not  so  long,  being 
almost  square.  There  is  a  difference  in  the  character  of  the 
head  in  the  two  forms.  The  former  variety  is  provided  with 
no  booklets,  but  has  four  suckers,  the  latter  having  both  booklets 
and  suckers.  "  The  head  is  about  the  size  of  a  mustard  seed 
and  is  pigmented." 
13 


194 


CARE  OF  INFANTS  AND  CHILDREN 


Symptoms, — There  frequently  are  few,  if  any,  symptoms 
present.  The  child  may  be  anaemic  and  otherwise  badly  nour- 
ished, but,  on  the  other  hand,  may  be  in  excellent  health. 

The  diagnosis  is  made  by  finding  segments  of  the  tapeworm 
in  the  stools.  The  segments  should  always  be  isolated  by  teasing 
them  out  in  water,  and  then  carefully  examining  them. 

Prophylaxis  consists  in  cooking  meat  sufficiently  well  to 
destroy  the  larvae. 

Treatment. — This  consists  in  giving  certain  drugs  with  the 
idea  of  expelling  the  worm,  including  the  head ;  otherwise  the 
worm  will  grow  again.  The  most  popular  drug  is  the  oleoresin 
of  the  male  fern.  The  medicine  should  be  preceded  by  several 
hours  of  fasting,  and  the  bowels  should  be  thoroughly  moved' 
by  means  of  a  saline  laxative.  One-half  hour  following  the 
last  dose  of  medicine,  a  half  ounce  of  castor  oil  should  be  given 
and  all  the  stool  saved  and  the  fragments  of  the  worm  teased 
out  in  water  in  order  to  find  the  head.  If  the  head  is  found  it 
is  known  that  the  "  cure  "  is  successful,  but  if  not  found  it  is 
always  doubtful. 

ROUND  WORM 

The  round  worm  (Fig.  93)  is  rarely  found  in  infancy,  but 
it  is  rather  common  in  children  after  the  third  year.  It  varies  in 
length,  averaging  about  six  inches,  the  female  being  somewhat 
longer  than  the  male.  It  is  cylindrical  in  shape,  tapering  at  both 
ends,  and  is  of  a  pinkish  grey  color.  The  eggs  are  extremely 
numerous,  being  numbered  by  millions,  and  are  about  1/4CX)  of 
an  inch  in  diameter. 

Number  of  Worms. — The  number  of  worms  which  may  be 
present  in  one  individual  may  vary  from  two  or  three  to  several 
hundreds.  A  coil  of  worms  may  be  so  large  as  to  produce  in- 
testinal obstruction.  The  manner  in  which  the  round  worm 
gains  entrance  to  the  digestive  tract  has  been  a  subject  of  much 
study.  It  is  probable  that  the  eggs  are  taken  in  with  the  food, 
particularly  in  uncooked  vegetables  and  salads.  It  is  found  that 
the  eggs  hatch  in  warm,  moist,  garden  earth  so  that  no  inter- 
mediate host  is  necessary. 


AFFECTIONS  OF  THE  DIGESTIVE  TRACT 


195 


Round  worms  may  migrate  from  the  small  intestine  into  the 
stomach,  the  bile-ducts,  the  pancreas,  and  they  have  been  found 
in  the  Eustachian  tube  and  middle  ear. 

Symptoms. — There  may  be  all  sorts  of  symptoms  produced 
by  the  presence  of  worms.  They  are  so  indefinite,  however, 
that  little  reliance  can  be  placed  upon  the  symptoms  alone  in 


Fic.  92. 


Fig.  93. 


Fig.  92. — Tapeworm,  showing  head  and  segment. 
Fig.  93. — Round  worm;    A,  female;  B,  male;  c,  egg. 


making  a  diagnosis.  The  important  thing  is  to  find  the  worms 
in  the  stool.  After  a  brisk  cathartic,  if  worms  are  present  some 
of  them  are  almost  sure  to  come  away  and  may  be  found  in  the 
stools.  Where  the  worms  are  not  found  in  the  stools  the  eggs 
surely  will  be  and  may  be  recognized  under  the  microscope. 

Treatment. — The  one  drug  which  is  relied  upon  for  the 
removal  of  this  form  of  worm  is  santonin.  It  should  not  be 
given  except  when  prescribed  by  a  physician. 


196 


CARE  OF  INFANTS  AND  CHILDREN 


PIN-WORM — THREAD-WORM 

This  form  of  parasite  (Fig.  94)  is  quite  common  in  children 
after  they  begin  to  eat  a  mixed  diet.  They  resemble  pieces  of 
white  thread  and  vary  from  one-third  to  half  an  inch  in  length. 
They  infest  the  lower  portion  of  the  colon  chiefly,  and  are  often 
found  in  great  numbers  mixed  with  the  stools.  The  eggs  are 
passed  in  great  numbers  and  are  found  in  the  folds  of  mucous 
membrane  about  the  anus  and  on  the  skin,  if  the  child  is  not 
kept  scrupulously  clean.  Children  may  thus,  if  allowed  to  scratch 
themselves  about  the  anus,  infect  them- 
selves over  and  over  again. 

Treatment. — When  the  worms  in- 
fest only  the  lower  portion  of  the  rectum 
they  are  usually  gotten  rid  of  without 
much  difficulty,  if  the  children  can  be 
kept   from   reinfecting  themselves.     If 
the  worms  infest  the  upper  portions  of 
the  colon  they  may  resist  treatment  for 
weeks  or  months. 
After  each  stool  the  skin  around  the  anus  should  be  thor- 
oughly washed  with  soap  and  water  and  a  diaper  or  closed 
pajamas  worn  to  prevent  scratching. 

Every  night  for  a  week  a  simple  injection  of  normal  salt 
solution  to  clear  the  bowel  should  be  given  at  bed-time,  after 
which  half  to  one  pint  of  quassia  infusion  should  be  allowed  to 
run  in  slowly,  the  pelvis  being  raised  slightly  so  that  it  will 
reach  high  in  the  colon.  This  should  be  retained  for  fifteen  or 
twenty  minutes.  After  the  first  week  the  injection  may  be  given 
every  second  night  for  another  week,  and  then  every  third  night 
for  still  another.  The  stools  should  be  watched  subsequently 
for  a  long  time  to  determine  if  there  has  been  any  rieturn  of  the 
condition. 

The  idea  that  pin-worms  produce  convulsions  and  epilepsy 
is  erroneous. 


Fig.  94. — Pin-  or  thread- worm. 
B,  eggs. 


CHAPTER  XXV 
DISEASES  OF  THE  RESPIRATORY  TRACT 

Acute  Nasal  Catarrh — Coryza 

Acute  coryza  is  a  very  common  aflfection  in  infants  and 
young  children.  That  it  is  due  to  an  infection  there  is  no  doubt ; 
neither  is  there  any  doubt  that  it  is  highly  contagious. 

If  one  child  is  put  in  a  ward  in  close  contact  with  other 
children  they  will  usually  contract  the  disease.  A  nurse  or 
mother  with  an  acute  coryza  should  take  every  precaution  not 
to  infect  the  baby.  The  mother  should  not  kiss  or  snuggle  the 
baby  while  she  has  a  coryza,  and  she  should  wear  several  thick- 
nesses of  gauze  over  her  mouth  and  nose  when  she  is  nursing 
the  baby,  such  as  a  surgeon  wears  during  an  abdominal  operation. 

The  beds  in  a  child's  ward  should  be  at  least  six  feet  apart, 
in  order  to  prevent  cross  infections. 

An  infant  with  acute  coryza  will  usually  have  some  fever, 
and  there  is  especial  difficulty  in  nursing  owing  to  obstruction 
to  breathing  through  the  nose.  The  result  is  that  the  baby  gets 
insufficient  food  and  loses  weight,  probably  as  a  result  of  insuffi- 
cient food  as  well  as  from  the  infection. 

Treatment. — Adrenalin  ointment  used  in  the  nose  every 
two  or  three  hours  will  usually  shrink  down  the  swollen  mucous 
membrane  so  that  some  air  will  pass  through.  Certain  drugs 
may  sometimes  be  combined  with  the  adrenalin  to  advantage. 

Complications. — In  many  cases  of  acute  coryza  the  inflam- 
mation does  not  limit  itself  to  the  nasal  passage,  but  the  post- 
nasal space  is  also  involved.  This  space  is  particularly  rich  in 
lymphatics  and  as  a  result  the  glands  on  the  sides  of  the  neck, 
cervical  and  postcervical,  are  often  enlarged.  If  the  infection 
is  severe  enough,  these  glands  may  break  down  and  form  ab- 
scesses, which  may  have  to  be  opened  and  drained.     Extension 

197 


198 


CARE  OF  INFANTS  AND  CHILDREN 


of  the  inflammation  from  the  f>ostnasal  space  to  the  Eustachian 
tubes  and  middle  ear,  or  mastoid,  is  common.  Infants  suffering 
from  an  acute  coryza  should  be  kept  indoors.  The  temperature 
of  the  room  should  be  uniform — about  70°  F. — and  the  air 
should  be  kept  moist  with  a  steam  kettle,  to  which  some  tincture 
of  benzoin  may  be  added.     This,  in  addition  to  the  adrenalin 

ointment,  is  all  that  is  usually 
needed.  No  irritating  sprays 
should  be  used. 

Adenoids 
The  lymphoid  tissue  in  the 
vault  of  the  pharynx  is  usually 
known  as  the  third  tonsil. 
When  this  lymphoid  tissue  be- 
comes enlarged  so  as  to  produce 
obstruction  to  nasal  breathing 
a  child  is  said  to  have  adenoids. 
An  enlargement  of  this  tis- 
sue may  occur  at  any  time  dur- 
ing infancy  or  childhood.  It  is 
not  infrequent  to  find  at  birth, 
or  soon  after,  the  postnasal 
space  so  filled  with  lymphoid 
tissue  that  the  baby  cannot 
breathe  through  the  nose  or 
nurse  properly  until  the  ob- 
struction has  been  removed.  In 
more  than  half  the  cases  there  is 
an  accompanying  enlargement  of  the  pharyngeal  tonsils.  The 
symptoms  of  adenoid  enlargement  are  usually  characteristic. 
The  child  breathes  through  the  mouth  instead  of  the  nose,  or  it 
may  breathe  partially  through  the  nose  when  awake,  but  when 
asleep  the  mouth  is  always  open.  Snoring  is  the  usual 
accompaniment. 

Mental  Apathy. — In  advanced  cases,  particularly  in  older 


Fig.  ')5. — Front  view  of  adenoid  face, 
Mark  the  open  mouth  and  broad-bridged 
nose. 


DISEASES  OF  THE  RESPIRATORY  TRACT  199 

children,  where  this  condition  has  persisted  for  a  considerable 
time,  the  face  has  an  idiotic  appearance.  The  mental  processes 
become  sluggish  and  the  child  is  frequently  sent  to  the  physician 
by  the  school  nurse  for  examination  (Figs.  95  and  96). 

Shape  of  the  Face. — As  a  result  of  this  improper  breathing 


Fig.  96. — Diagram  showing  position  of  adenoid  tissue. 

there  is  frequently  a  deformity  of  the  face  and  mouth,  as  well  as 
of  the  chest.  In  case  of  a  combination  of  mouth-breathing  and 
rickets,  the  deformities  are  especially  marked  and  are  apt  to  be 
more  or  less  permanent. 

Cough  Due  to  Adenoids. — Children  with  adenoids  are  apt 


200  CARE  OF  INFANTS  AND  CHILDREN 

to  suffer  from  a  chronic  cough  due  to  pharyngitis  as  a  result  of 
the  mouth-breathing.  Attacks  of  asthma  in  susceptible  individ- 
uals are  prone  to  be  markedly  exaggerated  by  adenoids.  I  have 
not  infrequently  seen  the  asthmatic  attacks  entirely  disappear 
when  the  adenoids  were  removed. 

Deafness. — The  fact  that  adenoids  often  obstruct  the  open- 
ings of  the  Eustachian  tubes  is  a  frequent  source  of  progressive 
deafness  in  children.  The  adenoids  interfere  with  the  drainage 
from  the  tubes  and  in  case  of  postnasal  infection  an  extension  of 
the  inflammation  to  the  middle  ear  is  common.  A  chronic  dis- 
charge from  the  ear  will  frequently  cease  as  soon  as  the  adenoids 
are  removed. 

Operation. — The  presence  of  adenoids  is  such  a  prolific 
source  of  trouble,  and  their  removal  so  simple  and  attended  with 
so  little  danger,  that  operation,  unless  there  is  some  special  con- 
traindication, should  always  be  recommended.  After  the  re- 
moval of  adenoids,  it  is  well  to  use  some  simple  antiseptic  solu- 
tion, such  as  10  per  cent,  argyrol,  to  be  dropped  through  the 
nose  when  the  head  is  well  back,  so  that  it  will  run  into  the 
postnasal  space,  until  the  raw  surf  ace  Js  healed. 

After-care. — In  case  of  any  infection  following  the  opera- 
tion, nasal  irrigation  with  normal  salt  solution  should  be  used 
frequently.  The  head  should  be  well  tipj)ed  forward  and  the 
fluid  allowed  to  make  the  circuit,  going  in  one  nostril  and  coming 
out  through  the  other. 

Earache — Abscess  of  the  Middle  Ear — ^Mastoiditis' 

Earache  is  a  common  affection  in  children.  Catarrhal  in- 
flammations of  the  nose  and  pharynx  are  very  apt  to  extend  to 
the  middle  ear,  producing  also  an  inflammation  of  the  drum 
membrane. 

The  condition  is  attended  with  severe  pain.  When  a  baby 
cries  severely  as  if  in  pain,  when  the  digestive  tract  appears  to 
be  in  order,  earache  should  always  be  thought  of.  If  present, 
the  dropping  of  some  warm  oil  or  glycerin  into  the  ear  will 


DISEASES  OF  THE  RESPIRATORY  TRACT  201 

usually  relieve  the  pain.  If,  however,  in  spite  of  this  simple 
treatment,  the  pain  persists  and  there  is  also  attending  fever, 
the  physician  should  be  called  and  an  examination  of  the  ear 
made  with  a  speculum  and  •  reflector.  Accumulation  of  fluid  in 
the  middle  ear  is  common  following  all  forms  of  inflammation 
of  the  nose  and  throat. 

Middle-ear  Abscess. — A  large  percentage  of  middle-ear  in- 
volvement is  due  to  infected  adenoids.  This  may  consist  of 
serum  or  pus.  If  of  serum,  it  may  absorb  or  be  discharged 
back  into  the  throat  without  perforating  the  drum.  If  of  pus, 
it  is  liable  to  continue  to  accumulate  until  it  perforates  through 
the  drum.  During  the  time  before  the  drum  perforates  there 
is  liable  to  be  considerable  pain  and  fever,  depending  upon  the 
kind  and  severity  of  the  infection.  In  infants  many  abscesses 
of  the  middle  ear  perforate  the  drum  of  themselves  without 
surgical  interference. 

Drum  Puncture. — A  child  with  a  middle-ear  inflammation 
should  always  be  under  the  care  of  a  physician  and  the  condition 
watched  carefully,  for  at  any  time  it  may  be  necessary  to  puncture 
the  drum.  After  the  drum  has  been  perforated  and  the  ear  is 
discharging  freely  it  is  only  necessary  to  keep  it  clean.  Irriga- 
tion is  not  so  much  in  vogue  for  this  purpose  as  formerly.  The 
ear  canal  should  be  wiped  out  with  cotton  and  most  ear  special- 
ists now  prefer  to  introduce  a  small  lamp-wick  drain  into  the 
entrance  of  the  canal,  to  be  changed  frequently.  In  order  to 
prevent  the  skin  in  the  lower  part  of  the  ear  from  becoming 
infected,  it  should  be  kept  clean  with  a  50  per  cent,  alcohol 
solution  and  then  smeared  over  with  vaseline,  lanoline,  or  oxide 
of  zinc. 

Medication  should  only  be  introduced  into  the  ear  canal 
under  the  direction  of  the  physician.  After  the  ear  has  stopped 
discharging  the  hearing  function  should  be  tested,  as  the  removal 
of  adenoids  or  the  inflation  of  the  Eustachian  tube  may  be 
necessary  to  prevent  deafness. 

Involvement  of  the  Mastoid. — In  a  certain  percentage  of 


202  CARE  OF  INFANTS  AND  CHILDREN 

cases  of  middle-ear  infection,  particularly  after  the  first  year, 
the  mastoid  also  becomes  involved.  Any  redness  or  swelling 
behind  the  ear  should  be  immediately  reported  to  the  physician, 
as  an  acute  inflammation  of  the  mastoid  usually  requires  prompt 
surgical  interference. 

Catarrhal  Laryngitis  and  Spasmodic  Croup 

Laryngitis  is  frequently  the  result  of  an  extension  of  a 
catarrhal  inflammation  from  the  nose  and  pharynx.  The  disease 
is  usually  manifested  by  hoarseness  and  cough.  In  case  the 
inflammation  is  severe  the  cough  may  be  almost  incessant. 

Spasmophilia. — Some  children,  particularly  those  of  the 
spasmophilic  diathesis,  are  prone  to  spasm  of  the  larynx  when- 
ever there  is  any  irritation  of  the  mucous  membrane  in  the  upper 
air  passages.  These  children  have  a  peculiarly  hoarse  cough, 
sometimes  with  marked  narrowing  of  the  laryngeal  opening,  and, 
as  a  result,  more  or  less  difficulty  on  inspiration. 

Laryngeal  Spasm. — A  laryngeal  spasm  may  occur  in  these 
children  when  no  inflammation  is  present.  Formerly  a  laryngitis 
accompanied  by  spasmodic  croup  was  confused  in  the  public 
mind  with  membranous  croup,  which  we  now  know  to  be 
diphtheria. 

Differentiation  from  Membranous  Croup. — Although 
the  two  conditions. are  entirely  diflferent,  there  is  sometimes  some 
difficulty  in  determining  whether  a  croup  is  spasmodic  in  char- 
acter or  whether  there  may  not  also  be  a  diphtheretic  membrane 
present. 

An  ordinary  spasmodic  croup  is  usually  transient  in  char- 
acter and  rarely  lasts  more  than  a  few  hours,  at  the  longest.  It 
is  relieved  by  antispasmodics,  such  as  syrup  of  ipecac,  given  in 
sufficient  doses  to  produce  vomiting  (15  to  60  drops). 

Steam  Tent. — A  steam  tent,  made  by  directing  the  steam 
from  a  tea-kettle  under  a  sheet  thrown  over  an  ordinary  child's 
crib,  will  usually  relieve  spasmodic  croup.  (Tincture  of  benzoin, 
I  teaspoon ful  to  a  pint  of  water,  may  be  added  with  benefit.) 


DISEASES  OF  THE  RESPIRATORY  TRACT 


203 


(See  Fig.  97.)  A  croup  which  persists  for  several  hours  after 
these  simple  remedies  have  been  tried  should  be  regarded  as 
suspicious.  A  physician  should  be  summoned  at  once  and  a 
culture  made  from  the  larynx. 

Ice-bags. — A  laryngitis,  with  or  without  an  accompanying 
croup,  is  usually  relieved  much  by  the  application  of  an  ice-bag 


Fig.  97.  —Steam  kettle  for  use  in  bronch'tis. 

to  the  front  of  the  throat,  or,  if  that  is  not  available,  a  cold 
compress  may  be  applied. 

Children  with  laryngitis  and  croup  should  be  kept  inside, 
out  of  the  wind  and  dust,  in  a  rather  uniform  moist  atmosphere, 
until  well. 

Cough  Mixtures. — Where  the  cough  is  severe  and  persist- 
ent, some  of  the  mucilaginous  cough  mixtures  to  which  some 
sedative  has  been  added  may  be  necessary. 


204  CARE  OF  INFANTS  AND  CHILDREN 

Bronchitis  and  Asthma 

Etiology. — Bronchitis  is  a  common  affection  in  infancy  and 
childhood.  In  many  cases  the  inflammation  is  simply  an  ex- 
tension of  a  process  begun  in  the  upper  air  passages.  Bronchitis 
may  be  due  to  a  variety  of  organisms,  the  most  common  of 
which  are  the  pneumococcus,  influenza,  staphylococcus,  and  the 
streptococcus. 

Symptoms. — The  symptoms  will  depend  upon  the  character 
and  severity  of  the  infection,  the  resistance  of  the  individual, 
and  the  extent  to  which  the  smaller  bronchi  are  involved.  In 
the  simple  forms  there  is  probably  little,  if  any,  involvement  of 
the  smaller  bronchi,  and  many  times  the  inflammation  is  limited 
to  the  larynx,  trachea  and  large  bronchi.  There  is  usually  some 
rise  of  temperature  (ioo°-ioi°  F.),  but  there  is  little  inter- 
ference with  breathing,  except  when  the  cough  is  especially 
troublesome,  which  is  usually  due  to  the  accompanying  laryngitis. 
Many  children  are  prone  to  attacks  of  bronchitis  and  with  every 
extreme  change  in  the  weather,  or  trifling  exposure,  they  begin 
to  cough. 

Predisposing  Causes. — Delicate  children  and  those  with 
adenoids,  tonsils  and  rickets  are  particularly  prone  to  attacks  of 
bronchitis.  Over-heated  houses,  and  particularly  steam-heated 
flats,  where  the  temperature  often  fluctuates  between  75°  and 
80°  F.  during  the  day,  and  is  allowed  to  go  down  to  nearly  the 
freezing  point  at  night,  are  common  predisposing  causes  of 
bronchitis. 

As  a  preventive  measure,  the  general  health  of  the  child 
should  be  maintained  at  as  high  a  point  as  possible  by  proper 
feeding  and  an  out-door  life.  Extremes  of  heat  and  cold  should 
be  avoided.  The  temperature  of  the  house  should  be  regulated 
by  a  thermostat  and  should  never  be  above  70°  F.  A  proper 
amount  of  moisture  in  the  air  should  be  maintained  by  vessels 
of  water  attached  to  the  radiators. 

Cool  Sponging. — Cool  sponging  of  the  chest  and  neck,  morn- 


DISEASES  OF  THE  RESPIRATORY  TRACT  205 

ing  and  evening,  with  a  vigorous  rub,  will  do  much  to  render 
these  children  less  sensitive  to  changes  in  temperature. 

Adenoids  a  Cause. — When  there  are  adenoids  they  should 
be  removed,  and  the  child  taught  to  breathe  through  the  nose, 
doing  daily  some  systematic  deep  breathing  and  at  the  same 
time  exercising  to  develop  the  chest.  Many  of  these  children 
have  small,  flat  chests  and  have  little  lung  capacity.  With 
systematic  training  the  lung  capacity  may  be  doubled  in  a  short 
time. 

For  the  acute  attacks,  compresses  to  the  chest,  hot  or  cold, 
as  indicated  in  the  individual  case,  inhalations  of  medicated 
steam,  and  the  simple  cough  mixtures  are  sometimes  indicated. 

Asthma 

Asthma  is  a  spasmodic  affection  of  the  bronchi,  resulting 
in  dyspnoea,  particularly  in  expiration.  There  is  considerable 
distress,  with  a  feeling  of  suffocation.  There  is  often  marked 
cyanosis.  The  breathing,  and  especially  the  expiration,  is  accom- 
panied over  the  entire  chest  by  a  wheezy,  crowing  sound,  as  a 
result  of  the  effort  on  the  part  of  the  chest  muscles  and  the 
diaphragm  to  force  the  air  from  the  vesicles  through  the 
narrowed  bronchi. 

According  to  many  authorities,  pure  spasmodic  asthma  in 
young  infants  is  rare.  The  asthma  usually  accompanies  and  is 
preceded  by  a  bronchitis.  Infants  with  exudative  diathesis 
(that  is,  those  prone  to  skin  affections  such  as  eczema)  are 
particularly  prone  to  attacks  of  asthma. 

Adenoids  as  Cause. — Adenoids  are  a  common  exciting  cause 
of  asthmatic  attacks  in  susceptible  children.  These  are  difficult 
cases,  and  in  the  northern  climate,  where  changes  in  the  weather 
are  sudden  and  extreme,  they  are  liable  to  recur  and  recur,  in 
spite  of  the  best  efforts  to  prevent.  Such  children  are  frequently 
much  benefited,  and  sometimes  permanently  cured,  by  spending 
a  winter  or  two  in  the  South  of  Florida  or  California,  where  they 
can  live  out  of  doors  the  entire  time. 


2o6  CAKE  OF  INFANTS  AND  CHILDREN 

.  For  the  attacks,  inhalations  of  some  of  the  antispasmodics 
may  have  to  be  used.  , 

Practically  all  of  the  patent  asthma  cures  are  only  palliative 
and  consist  of  drugs  well  known  to  every  physician. 

Influenza,  La  Grippe 

Influenza  is  an  acute  infectious  disease  due  to  the  influenza 
bacillus  first  described  by  Pfeiffer  in  1892.  The  disease  is  highly 
contagious  and  has  a  disposition  to  occur  in  wide-spread 
epidemics. 

In  many  cases  it  begins  with  a  catarrhal  inflammation  of  the 
respiratory  tract ;  this  may  be  mild  or  severe,  not  uncommonly 
extending  to  the  bronchi  or  to  the  alveoli  of  the  lungs,  producing 
pneumonia.  The  inflammation  may  extend  from  the  nasal  pas- 
sages into  any  of  the  adjoining  sinuses,  so  that  involvement  of 
the  middle  ear,  mastoid,  antrum,  and  frontal  and  ethmoidal 
sinuses,  are  common  complications.  Enlargement  of  the  cer- 
vical lymph-glands  is  exceedingly  common.  Involvement  of  the 
digestive  tract  is  frequent,  vomiting  and  diarrhoea  being  a  com- 
mon accompaniment.  Meningitis  as  a  result  of  infection  from 
general  circulation  or  extension  from  the  ethmoidal  or  mastoid 
sinuses  is  not  uncommon. 

The  disease  runs  an  extremely  variable  course,  depending 
upon  the  severity  of  the  infection,  the  resistance  of  the  individ- 
ual, and  the  character  of  the  complications.  The  temperature 
may  make  wide  excursions,  varying  from  99°  to  106°  during 
the  24  hours.  Marked  nervous  symptoms  are  usually  present, 
the  most  common  being  headaches,  stupor,  delirium,  and,  in 
young  infants  with  spasmodic  diathesis,  convulsions.  Fresh  air 
is  one  of  the  first  essentials.  If  there  is  marked  involvement  of 
the  respiratory  tract,  the  air  should  be  warm  and  moist ;  when 
the  air  is  cold,  the  coughing  is  increased.  Inhalations  of  steam 
and  tincture  of  benzoin  (one  teaspoon  to  one  pint  of  water)  are 
often  followed  by  marked  relief. 

When  the  digestive  tract  is  involved  the  food  must  be  much 


DISEASES  OF  THE  RESPIRATORY  TRACT  207 

restricted.  When  cow's  milk  is  vomited  or  when  it  is  found  in 
the  stools,  improperly  digested,  it  should  be  either  entirely 
eliminated  for  a  few  days  or  given  much  diluted.  When  the 
(temperature  is  high  and  the  child  is  restless  or  delirious,  cool 
packs  of  alcohol  and  water  or  cool  sponging  will  frequently  be 
followed  by  improvement  of  all  the  symptoms. 

There  is  a  marked  tendency  to  relapse  even  after  the  tem- 
perature has  been  normal  for  some  days.  Convalescence  is 
frequently  slow  and  there  is  liable  to  be  more  or  less  anaemia 
and  a  lack  of  vitality  for  some  time.  Nutritious  food  is  of 
vital  importance.  Patients  should  be  gotten  out  of  doors  as 
soon  as  possible,  although  in  the  northern  climate  in  winter  it  is 
sometimes  difficult  to  decide  just  when  it  is  safe  to  take  young 
children  out  of  doors,  especially  if  there  has  been  a  complicating 
pneumonia.  Many  of  these  cases  are  immensely  benefited  by  a 
trip  to  the  country  or  to  the  seashore  where  they  can  be  out  of 
doors  during  the  entire  twenty-four  hours.  Where  the  cough 
persists  and  the  vitality  does  not  soon  return  a  critical  physical 
examination  should  be  made  by  the  physician,  having  in  mind 
the  possibility  of  tuberculosis.  Complications,  such  as  pneu- 
monia and  mastoiditis,  will  be  taken  up  later  under  their  par- 
ticular headings. 

Bronchgpneumgni.v 

Bronchopneumonia  is  a  frequent  and  serious  affection  of 
infants  and  young  children.  It  is  particularly  prone  to  attack 
those  infants  whose  vitality  for  any  reason  has  been  reduced. 
It  is  a  common  complication  of  the  acute  contagious  diseases, 
whooping-cough  and  measles,  furnishing  many  of  the  serious 
and  fatal  cases. 

Etiology. — The  disease  is  due  to  a  variety  of  organisms, 
pneumococci,  streptococci,  and  the  influenza  bacillus  being  the 
common  ones  found  in  the  sputum  of  these  cases.  The  disease 
is  known  under  various  other  names,  as  catarrhal  pneumonia, 
capillary  bronchitis,  and  lobular  pneumonia. 


2o8 


CARE  OF  INFANTS  AND  CHILDREN 


The  disease  frequently  begins  as  a  bronchitis  and  extends 
into  the  small  bronchi  and  air  vesicles,  setting  up  an  inflam- 
mation with  more  or  less  exudate,  which  partially  fills  these 
portions  of  the  lungs,  resulting  often  in  serious  curtailment  of 
lung  space,  resulting  in  marked  dyspnoea.  The  temperature  is 
variable,  usually  of  a  remittent  character  (Fig.  98). 

Duration. — The  disease  under  favorable  conditions  is  liable 
to  last  several  weeks.    The  temperature  usually  falls  gradually 


Tmnttx 

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Fig.  98. — Temperature  curve  in  bronchopneumonia. 

by  lysis  in  contradistinction  to  lobar  pneumonia,  which  usually 
ends  suddenly  by  crisis. 

ExACERB.\TiONS. — During  the  course  of  the  disease  there 
are  liable  to  be  marked  exacerbations.  The  patient  will  seem 
to  be  getting  on  well,  the  temperature  gradually  becoming  lower, 
with  general  betterment  of  all  the  symptoms,  then  the  tempera- 
ture will  suddenly  shoot  up  again  and  the  general  condition 
may  become  worse  than  before.  These  exacerbations  are  caused 
undoubtedly  by  new  areas  of  involvement  in  the  lung. 


DISEASES  OF  THE  RESPIRATORY  TRACT  209 

Lung  Areas  Involved. — It  is  not  uncommon  in  broncho- 
pneumonia to  find  areas  of  consolidation  which  may  involve  a 
considerable  portion  of  one  or  more  lobes.  Many  of  these  are 
mixed  infections  and  are  really  both  lobar  and  bronchopneumonia 
combined. 

Nursing. — The  proper  nursing  of  these  cases  is  the  most 
important  element  in  the  treatment.  The  essential  thing  is  to 
maintain  in  every  way  the  vitality  of  the  patient  to  enable  him  to 
overcome  the  infection. 

Diet. — In  young  infants  the  food  should  be  breast  milk ;  for 
older  children,  milk  and  buttermilk.  Concentrated  gruels  with 
fruit  juices  make  an  excellent  combination. 

Care  of  the  Mouth  and  Nose. — The  mouth  and  nose  re- 
quire special  care.  The  teeth  and  tongue,  which  become  covered 
with  dried  secretion,  should  be  kept  scrupulously  clean  by 
gentle  brushing  with  some  mild  alkaline  and  antiseptic  solution, 
such  as  Seller's  or  Dobell's  solution.  The  nose,  where  there  is 
much  secretion,  should  be  douched  at  least  morning  and  evening 
by  means  of  a  nonnal  salt  solution.  In  some  cases  liquid  albo- 
lene  dropped  into  the  nose  when  the  head  is  well  back  will  result 
in  keeping  the  nasal  passages  reasonably  free  from  accumulated 
secretions.  This  is  best  done  by  using  a  nasal  irrigator  with  a 
blunt  point.  The  head  should  be  tipped  well  forward  over  a 
dish  and  the  solution  allowed  to  run  in  one  nostril  and  out  the 
other.  In  the  interval,  in  order  to  keep  the  nasal  passage  open, 
some  simple  ointment,  such  as  adrenalin,  to  which  some  camphor 
and  menthol  have  been  added,  will  be  of  great  benefit  in  pre- 
venting crusts  from  forming.  When  cleanliness  in  the  nose 
and  mouth  is  not  practised  in  these  cases,  reinfection  of  the 
lungs  may  occur  over  and  over  again,  and,  in  addition,  severe 
general  poisoning  from  absoption,  thereby  greatly  lessening  the 
chances  for  recovery. 

Sponging. — When  the  temperature  is  high  and  there  is 
marked  restlessness,  sponging  with  tepid  water  and  alcohol  will 
improve  the  condition.     Thick  pneumonia  jackets  should  never 

14 


210  CARE  OF  INFANTS  AND  CHILDREN 

1)0  used  in  these  cases;  they  simply  keep  u[)  the  temperature  hy 
])re\entini,^  the  necessary  loss  of  heat.  A  woollen  shirt,  which 
can  he  easily  removed,  is  all  that  is  necessary  in  the  way  of 
clothing.  Applications  in  the  way  of  compresses  (one-half 
alcohol,  one-half  water),  which  may  be  indicated  during  the 
course  of  the  disease,  may  then  be  made  and  removed  as  required. 
After  one  attack  of  bronchopneumonia  the  patient  is  much 
more  susceptible  to  subsequent  attacks.  Children  should  spend 
the  summer  in  the  open,  and  if  possible  in  the  pine  woods,  and 
if  the  finances  of  the  family  will  permit,  the  following  winter 
should  be  spent  in  the  South.  A  nutritious  diet,  with  the  addi- 
tion of  cod-liver  oil  in  cases  where  it  can  be  tolerated,  will  be  an 
essential  part  of  the  program  in  the  convalescence  of  these  cases. 

Lobar  Pneumonia 

Etiology. — Lobar  pneumonia  is  a  frequent  disease,  afifect- 
ing  children  of  all  ages.  It  is  much  more  common  in  infants 
than  is  generally  conceded.  The  disease  is  due  to  the  pneumo- 
coccus.  It  would  therefore  be  more  correct  to  call  the  disease  a 
pneumococcus-pneumonia  instead  of  a  lobar  pneumonia,  as  fre- 
quently the  disease  does  not  alTect  a  whole  lobe,  but  only  a 
portion  of  a  lobe,  or  portions  of  several  lobes  at  the  same  or 
different  times.  The  characteristic  thing  which  marks  the  dis- 
ease as  being  of  pneumococcic  origin  is  its  typical  course.  The 
course  is  frequently  identical  with  that  in  adults. 

Initial  Chill. — The  onset  is  usually  sudden,  beginning  with 
a  chill,  or  in  young  children  this  may  take  the  form  of  a  con- 
vulsion. The  temperature  becomes  suddenly  elevated,  and  there 
is  usually  a  short  cough. 

Character  of  Respiration. — The  respiration  is  superficial, 
more  rapid  than  normal,  and  at  the  end  of  inspiration  there  is 
frequently  a  short  gnmt.  If  the  pneumonia  is  limited  to  one 
side  there  is  usually  some  noticeable  lack  of  expansion  of  the 
afifected  side.  The  temperature  remains  high,  with  slight  morn- 
ing and  evening  remissions,  and  the  pulse  and  respirations  are 


DISEASES  OF  THE  RESPIRATORY  TRACT  21 1 

usually  correspondingly  increased  in  frequency.  The  respira- 
tions may  be  increased  out  of  proportion  to  the  teni[)erature. 
In  young  infants  the  breathing  is  largely  abdominal,  so  that  it 
is  somewhat  difficult  to  register  the  frequency  except  by  close 
inspection. 

The  face  is  usually  flushed  and  one  cheek  is  liable  to  be  much 
more  so  than  the  other.    Herpes  on  the  lips  is  the  rule. 

The  tongue  is  usually  dry  and  coated,  but  there  may  be  sur- 
})risingly  little  difficulty  with  the  digestion,  especially  if  the 
baby  is  breast-fed.  It  will  usually  be  satisfied  with  small  amounts 
of  food,  and  if  over-fed  the  stools  are  liable  to  be  green  and 
curdy.  There  is  usually  great  restlessness,  often  with  muttering 
delirium. 

The  Crisis. — The  disease  usually  runs  a  typical  course  of 
from  5-9  days,  sometimes  longer  and  occasionally  shorter,  and 
ends  suddenly  by  a  crisis,  the  temperature  within  a  few  hours 
dropping  to  normal  or  even  slightly  below  (Fig.  99).  After  a 
few  hours  there  is  liable  to  be  a  slight  rise  to  99°,  or  perhaps 
99.5°  F.,  after  which  it  remains  normal,  or  almost  so.  With  a 
drop  in  the  temperature  there  is  also  general  improvement  in 
the  other  symptoms ;  the  respirations,  which  have  been  per- 
haps 40  to  60  per  minute,  drop  to  25  or  less,  and  the  pulse,  in- 
stead of  running  at  140-160  per  minute,  is  found  to  be  soft  and 
almost  normal  in  frequency. 

The  disease  has  run  its  course  and  has  formed  its  own 
antitoxin. 

PsKUDOCRisis. — Occasionally  it  happens  that  the  sudden  drop 
in  temperature  was  not  a  real  crisis  but  a  pseudocrisis.  and  is 
followed  after  a  few  hours  by  a  sudden  rise  in  temperature, 
which  may  persist  for  several  days  with  as  severe  symptoms  as 
before.  It  will  usually  be  found  that  such  a  drop  in  the  tem- 
perature is  followed  by  a  new  involvement  in  the  lung,  either 
as  an  extension  from  the  original  consolidation,  or  in  another 
lobe,  or  even  in  the  other  lung. 

Pneumococcus-pneumonia     (lobar    pneumonia)    is    a    self- 


212 


CARE  OF  INFANTS  AND  CHILDREN 


limited  disease,  but  there  is  no  other  disease  which  runs  such  a 
short  and  critical  course. 

Treatment. — There  is  no  doubt  that  many  cases  of  pneu- 


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Fig.  99. — Temperature  curve  in  lobar  pneumonia. 

monia  are  over-treated.  Enough  should  be  done  for  the  patient, 
but  not  too  much.  An  abundance  of  fresh  air  should  always 
be  allowed  patients  with  pneumonia.     Young  infants  and  chil- 


DISEASES  OF  THE  RESPIRATORY  TRACT  213 

dren  should  not  be  subjected  to  zero  or  sub-zero  temperature. 
If  infants  when  normal  tolerate  extreme  cold  badly,  they  will 
hardly  tolerate  it  better  when  suffering  with  pneumonia. 

Pneumonia  Jackets. — Pneumonia  jackets  of  several  layers 
of  cotton  and  oiled  silk  should  never  be  worn  in  cases  where 
the  temj>eraturfe  is  running  high,  as  they  simply  serve  to  keep 
the  'temperature  higher. 

Alcohol  Compresses. — A  much  better  appliance,  which  will 
control  the  temperature  within  certain  limits  and  make  the  pa- 
tient much  more  comfortable  and  less  delirious,  is  an  alcohol  and 
water  compress  applied  around  the  chest,  one-third  alcohol  and 
two-thirds  water,  covered  with  a  woollen  blanket  (Fig.  100). 
The  compress  may  be  applied  warm  or  cold,  as  indicated.  The 
compress,  which  may  consist  of  a  bath  towel,  may  be  wet  occa- 
sionally without  removing  it.  It  will  be  found  that  children 
resent  sponging  with  cold  water.  The  compress  relieves  the 
necessity  for  sponging  and  is  much  more  effective.  These  chil- 
dren should  be  given  water  freely.  The  bowels  should  be  kept 
open  if  necessary,  but  if  normal  should  be  left  alone. 

Care  of  Mouth. — The  mouth  <and  nose  require  special  care 
and  ''should  be  kept  as  free  from  secretions  as  possible  without 
annoying  the  patient  constantly,  often  to  his  detriment. 

Pleurisy. — Lobar  pneumonia  is  usually  accompanied  by 
pleurisy.  This  is  a  complication  which  is  usually  painful,  some- 
times producing  marked  interference  with  the  breathing.  It  is 
occasionally  necessary  under  these  conditions  to  strap  the  affected 
side  with  adhesive  plaster  strips. 

Pleural  Effusion. — A  pleural  effusion  occasionally  fol- 
lows pneumonia.  The  fluid  may  be  simply  a  serum  which  may 
either  absorb,  or,  if  large  in  quantity,  may  have  to  be  withdrawn 
by  aspiration. 

Empyema. — A  more  serious  and  usual  complication  is  the 
formation  of  pus  in  the  pleural  cavity,  a  condition  known  as 
empyema.  After  the  pneumonia  is  apparently  over  there  is  a 
sudden  rise  in  temperature,  which  is  persistent  and  of  a  remittent 


214  CARE  OF  INFANTS  AND  CHILDREN 

character,  usually  quite  different  from  that  during  the  course  of 
the  pneumonia.  The  affected  side  is  usually  fixed  and  the 
physical  signs  are  riiosc  of  fluid  instead  of  consolidation.     In 


Fig.    100.-  Manner  of  applying  a  compress  to  the  chest.      This  .should  be  covered  with 

flannel. 

young  infants  the  pus  is  usually  withdrawn  by  aspiration.  This 
may  have  to  be  repeated  several  times  before  the  accumulation 
ceases  to  return.    In  older  children  a  resection  of  a  rib  is  usually 


DISEASES  OF  THE  RESPIRATORY  TRACT  215 

made  at  the  lowest  point  of  the  cavity.  Some  form  of  drain  is 
usually  introduced  and  maintained  until  the  pus  ceases  to  come 
from  the  pleural  cavity,  when  the  opening  is  allowed  to  close. 
The  dressing  should  be  changed  sufficiently  often  to  absorb  all 
discharges.  The  skin  should  be  washed  with  alcohol  after  each 
dressing  and  afterwards  smeared  with  some  simple  ointment, 
such  as  vaseline  or  oxide  of  zinc,  to  protect  it  from  the  discharges. 

Pleurisy 

Pleurisy  in  young  infants  and  children  is  comparatively  rare 
as  a  primary  disease.  It  most  commonly  comes  as  a  complica- 
tion of  pneumonia  as  described  under  lobar  pneumonia  or  as  a 
secondary  tuberculous  infection. 

If  tubercular,  the  treatment  will  be  that  of  tuberculosis,  and 
if  there  is  a  large  amount  of  fluid  it  may  have  to  be  drained  off 
by  aspiration. 


CHAPTER  XXVI 


DISEASES  OF  THE  BRAIN  AND  CENTRAL 
NERVOUS  SYSTEM 

Obstetrical  Paralysis 
Many  of  the  nervous  affections  from  which  new-born  in- 
fants suffer  are  due  to  accidental  injuries  at  birth.     In  a  difficult 
delivery  it  is  often  necessary  to  apply  traction  to  the  extremities, 

resulting  not  infrequently  in 
injury  to  the  nerve  trunks, 
causing  paralysis  of  the  mus- 
cles supplied  by  these  nerves 
(Fig.  loi).  Fortunately, 
many  of  the  cases  of  ob- 
stetrical paralysis  are  tem- 
porary in  character,  and  result 
after  a  few  weeks  or  months 
in  perfect  recovery. 

Injury  to  the  brain  or  its 
membranes,  owing  to  compres- 
sion in  the  pelvic  canal  or  to 
the  application  of  forceps,  is 
more  serious  and    frequently 
results  in  a  meningeal  hemor- 
rhage and  in  some  degree  of 
paralysis  of  the  muscles  con- 
trolled   by   the    area    pressed 
upon.       Nervous     symptoms, 
such  as  convulsions,:  frequently 
develop  in  the  new-bom,  and 
it  is  impossible  for  the  time  being  to  determine  whether  they  are 
functional  or  whether  they  are  due  to  some  injury  to  the  brain. 
Little's  Disease. — There  are  other  affections  of  the  brain, 
216 


Fig. 


101. — Facial    paralysis   due   to   injury 
at  birth. 


DISEASES  OF  THE  BRAIN 


217 


such  as  general  spastic  paralysis  (Little's  disease),  microcephalus 
and  mongolism,  which  are  undoubtedly  due,  many  times,  to 
some  intra-uterine  injury,  or  perhaps  to  injury  during  birth, 
where  the  condition  is  not  recognized  until  the  child  is  several 
months  old  (Fig.  102).  A  nurse  who  is  a  keen  observer  will 
usually  have  noticed   in   these   children   before   many   months 


Fig.    102. — Little's  disease  (spastic  paralysis). 

that  there  is  something  wrong  either  in  the  character  of  the 
muscular  movements  (rigidity)  or  in  the  mentality,  and  will 
call  the  physician's  attention  to  the  fact. 

A  baby  who  at  the  age  of  six  months  does  not  grasp  objects 
with  its  hands,  and  stick  them  directly  into  its  mouth,  is  not 
normal. 


2i8  CARE  OF  INFANTS  AND  CHILDREN 

When  several  incoordinate  attempts  must  be  made  in  order 
to  grasp  an  object,  the  fingers  being  in  extension,  and  then  often 
imperfectly  closing,  the  object  being  carried  to  the  mouth  in  a 
zig-zag  manner.  Little's  disease  should  be  suspected.  The  legs 
and  feet  in  these  cases  may  be  quite  as  spastic  as  the  arms  and 
hands,  and  it  will  be  noticed  that  any  attempt  to  separate  the 
thighs  results  at  once  in  a  spasm  of  the  muscles.  In  many  cases 
there  is  also  a  spastic  condition  of  the  muscles  of  the  face  and 
jaws,  so  that  later  mastication  of  the  food  is  difficult. 

Although  these  cases  are  incurable,  much  can  be  done  by 
proper  education  of  the  muscles  and  by  the  use  of  appliances  to 
improve  their  usefulness.  Later  on  surgical  measures,  such  as 
transplantation  of  certain  tendons^  may  greatly  improve  the 
ability  of  getting  around. 

Unless  properly  advised  many  of  these  cases  get  into  the 
hands  of  charlatans,  who  take  the  parents'  money  and  promise 
results  which  they  cannot  obtain. 

Microcephalic  Idiots 

As  a  rule  these  cases  cannot  be  diagnosed  at  birth.  For- 
some  reason  there  is  an  arrested  development  of  the  brain,  and 
after  a  few  months  it  will  be  noticed  that  the  head  is  smaller 
than  normal.  The  sutures  and  fontanelles  are  frequently  en- 
tirely closed  at  the  age  of  six  months.  It  was  thought  formerly 
that  the  arrested  brain  development  was  due  to  premature 
closure  of  the  sutures  and  fontanelles.  It  is  now  practically 
certain  that  in  the  majority  of  cases  at  least  the  reverse  is  the 
case. 

There  is  little,  if  any,  mental  development  in  most  of  these 
cases,  and  many  of  them  are  subject  to  convulsive  seizures  of 
various  degrees  of  severity  (Fig.  103). 

Congenital  Hydrocephalus — "  Water  on  the  Brain  " 
This  condition  is  characterized  by  an  accumulation  of  fluid 
in  the  ventricles  of  the  brain.    A  form  in  which  the  fluid  collects 
external  to  the  brain,  between  the  membranes,  is  rare  and  will 
not  be  discussed  here. 


DISEASES  OF  THE  BRAIN  219 

Chronic  hydroccplialiis  is  usually  congenital,  although  it  may 
follow  basilar  meningitis. 

The  head  gradually  increases  in  size,  the  edges  of  the  sutures 
are  separated  further  and  further,  the  fontanelles  becoming 
larger.  In  some  cases  where  the  child  lives  to  be  several  years 
of  age  the  head  reaches  an  enormous  size  (Fig.  104).  The 
amount  of  fluid  which  accumulates  in  the  ventricles  varies  from 


Fig.  103. — Microcephalus.  Child  two  and  one-half  years.    Circumference  of  head,  13  inches. 

several  ounces  to  several  pints.  Holt  reports  a  case,  which  died 
at  four  months,  from  which  five  pints  of  fluid  were  removed 
from  the  brain. 

It  is  surprising  how  long  many  of  these  cases  live  and  con- 
tinue to  be  fairly  normal  in  many  of  their  functions.  Some  of 
them  are  extremely  bright.  One  child,  now  three  years  old, 
with  a  head  circumference  of  28  inches,  is  unusually  intelligent 
for  her  years.  Many  of  them  are  backward  mentally,  and  some 
are  idiotic. 


220 


CARK  OF  INF/VxNTS  AND  CHILDREN 


The  symptoms  vary  greatly,  depending  upon  how  early  the 
condition  began  and  the  rapidity  with  which  the  fluid  ac-/ 
cumulates.  The  great  majority  of  these  cases  die  before  they 
reach  the  end  of  the  first  year.  "  It  is  comparatively  rare  that  a 
case  of  congenital  hydrocephalus  reaches  the  seventh  year."  A 
few  reach  adolescence,  the  process  having  after  a  time  ceased  to 
develop  further.  Some  cases  go  through  life  with  a  markedly 
enlarged  head,  and  usually  with  a  mental  condition  somewhat 
impaired. 

Treatment. — If  there  is  a  possibility  of  syphilis  being  the 


Fig.   104. — Chronic  internal  hydrocephalus  in  child  twelve  months  of  age. 

cause,  active  antisyphilitic  treatment  should  be  begun  early. 
Draining  the  ventricles  into  the  subarachnoid  space  has  been 
tried  with  varying  degrees  of  success,  but  so  far  the  mortality 
has  been  large  and  the  results  in  the  cases  which  survived  the 
operation  not  brilliant. 


Mongolism — Mongolian   Idiots 

This  represents  a  class  of  idiots  which  have  the  peculiar 
faces  of  the  MongoHan  (Fig.  105).  The  condition  is  often  mis- 
taken for  cretinism,  although  there  are  few  symptoms  which  are 
sufficiently  similar  to  warrant  confusion.     Like  other  forms  of 


DISEASES  OF  THE  BRAIN  221 

1 


Fig.   105. — Mongolian  idiot. 


idiocy,  it  is  of  various  grades.  In  the  milder  forms  there  is 
some  possibility  of  mental  development,  although  slow  and 
always  limited. 

Nurses   should  never  suggest  the  possibility  of   idiocy  or 


222 


CARE  OF  INFANTS  AND  CHILDREN 


feeble-mindedness  to  the  parents.    No  one  but  a  physician  should 
take  such  a  responsibiHty. 

Malformations  of  Brain  and  Spinal  Cord 
There  are  several  forms  of  malformation  of  the  brain  and 


Fig.   106. — Spina  bifida  in  dorsal  region. 

spinal  cord  which  arc  due  to  defects  in  the  skull  or  vertebrse, 
allowing  a  portion  of  the  brain  or  spinal  cord  or  their  membranes 
to  protrude  through  the  opening. 

In  meningocele  there  is  a  protrusion  of  the  membranes  of  the 


DISEASES  OF  THE  BRAIN 


223 


brain  through  an  opening  in  the  skull  or  spinal  column.     The 
tumor  is  usually  in  the  form  of  a  sac  tilled  with  lluid. 

In  cnccphalocele  there  is,  in  addition  to  the  membranes,  a 
protrusion  of  some  of  the  brain  substance. 


SPINA    BIFIDA 


There  is  a  malformation  of  the  vertebral  canal  with  a  pro- 
trusion of  some  of  the  membranes  through  the  opening,  usually 


Fig.    107. — Spina  bifida  in  lumbar  region. 

filled  with  .spinal  fluid  similar  to  meningocele  (Figs.  106  and 
107).  The  prognoses  in  these  cases  will  depend  largely  on 
whether  a  portion  of  the  cord  or  nerve  trunks  is  incorporated 
in  the  sac.  If  so.  the  paralysis  is  usually  permanent,  with 
little  or  no  hope  of  relief  by  surgical  or  any  other  means.  Even 
in  favorable  cases,  operation  occasionally  is  followed  by  internal 
hydrocephalus.  The  skin  over  the  mass  is  often  xQxy  thin  and 
great  care  must  be  taken  lest  there  be  an  abrasion  and  the  spinal 
fluid  escape.  An  ascending  infection  of  the  spinal  meninges  is 
practically  sure  to  follow.  A  soft  cotton  ring  surrounding  the 
tumor  will  serve  to  protect  it  from  injury. 


224 


CARE  OF  INFANTS  AND  CHILDREN 


Con \'ULS IONS  and  Etilki'sy 

Convulsions  are  among  the  most  common  nervous  affections 
of  infancy. 

There  is  a  certain  type  of  children  v^ho  have  a  constitutional 
predisposition  to  convulsions.  A  child  of  this  type  is  said  to 
have  "  the  spasmodic  diathesis  "  (spasmophilia),  meaning  that  it 
has  a  predisposition  to  convulsive  seizures.  Such  children  are 
prone  to  have  a  convulsion  with  an  attack  of  indigestion,  or  with 
the  onset  of  any  of  the  infectious  diseases. 

Convulsions  are  liable  to  occur  in  any  child,  as  a  result  of 
infections  of  the  brain  and  meninges  or  from  intracranial 
pressure. 

When  a  child  is  suddenly  seized  with  a  convulsion,  it  is  usually 
impossible  to  say  whether  it  is  due  to  functional  causes  or 
whether  it  may  not  indicate  the  onset  of  one  of  the  infectious 
diseases,  or  a  meningitis.  If  the  convulsion  is  due  to  indigestion, 
which  is  the  most  common  cause  in  susceptible  individuals,  it  will 
be  relieved  after  the  intestinal  canal  has  been  cleared  out,  and 
after  sufficient  time  has  elapsed  to  eliminate  the  toxic  agents  and 
allow  the  nervous  system  to  regain  its  equilibrium. 

Sedatives. — Sedatives,  such  as  chloral,  bromide,  or  some- 
times chloroform,  may  be  necessary  to  control  the  convulsive 
seizures.  Plunging  these  cases  at  once  into  hot  water,  and  at  the 
same  time  keeping  the  head  cool,  is  often  effective.  Great  care 
must  be  taken  lest  the  water  be  too  hot  and  result  in  a  serious 
burn.  If  the  temperature  is  high,  the  child  should  be  rolled  in 
a  cool  pack,  made  by  wringing  a  bath  towel  out  of  cool  water  to 
which  some  alcohol  may  be  added. 

In  many  cases  the  convulsion  which  comes  with  the  onset  of 
one  of  the  acute  infections  really  corresponds  to  the  initial  chill 
in  the  adult,  and  may  or  may  not  be  repeated. 

Epilepsy  and  Spasmophilia. — When  a  child  has  a  convul- 
sion at  intervals  of  several  weeks  or  months,  and  without  any 
apparent  provocation,  there  is  always  some  fear  in  the  minds  of 


DISEASES  OF  THE  BRAIN  225 

the  parents  that  the  condition  may  be  epilepsy.  That,  of  course, 
is  quite  possible  and  will  require  skilful  and  close  analysis  to 
determine.  There  are,  however,  certain  characteristic  muscular 
reactions  in  spasmophilia  to  electrical  and  mechanical  stimuli,  by 
which  the  two  conditions  may  often  be  differentiated. 

The  convulsions  which  accompany  the  different  forms  of 
meningitis  and  brain  injuries  will  usually  be  associated  with 
other  characteristic  symptoms. 

Feeding. — Children  who  are  prone  to  convulsions  should  be 
fed  and  handled  with  the  greatest  care.  The  parents,  one  or 
both,  are  often  neurotic  and  a  history  of  convulsions  in  infancy 
can  frequently  be  obtained.  Many  of  these  children  are  over- 
fed with  cow's  milk.  The  milk  should  be  much  reduced  and  a 
mixed  diet  given  as  soon  as  possible.  Albumin  milk,  from  which 
most  of  the  salts  have  been  removed,  is  an  ideal  diet  in  these 
cases,  supplemented  as  soon  as  possible  with  other  food.  In 
some  cases  the  cream  of  the  milk  will  have  to  be  largely 
eliminated.  The  fat  may  be  supplied  to  advantage  by  giving  cod- 
liver  oil  in  proper  amounts.  The  addition  of  small  doses  of 
phosphorus  is  often  advisable.  These  children  should  live  in  the 
open  air  and  be  removed  from  all  excitement.  If  their  physical 
condition  can  be  markedly  improved,  the -nervous  irritation  will 
usually  improve  also.  It  must  also  be  borne  in  mind  that  most  of 
these  cases  have  inherited  a  nervous  temperament,  and  although 
much  may  be  done  in  improving  their  physical  condition  and  in 
teaching  them  self-control,  the  temperament  is  there  and  will  not 
be  fundamentally  changed. 

EPILEPSY 

"  Epilepsy  may  be  described  as  an  unstable  condition  of  the 
nervous  system,  resulting  at  intervals  in  an  explosion  of  nervous 
energy,  convulsive  movements  of  the  muscles,  and  temporary 
loss  of  consciousness."  The  attacks  come  at  irregular  intervals, 
many  times  without  any  apparent  exciting  cause,  although  undue 
excitement  and  indigestion  are  apt  to  precipitate  them.  The 
15 


226  CARE  OF  INFANTS  AND  CHILDREN 

condition  is  chronic,  and,  although  it  may  be  modified  somewhat, 
hists  throughout  life. 

According  to  Gowers,  12  per  cent,  of  the  cases  begin  during 
the  first  three  years  of  life,  and  46  per  cent,  between  ten  and 
twenty  years. 

Heredity  plays  an  important  role  in  producing  the  disease, 
and,  according  to  Gowers,  about  one-third  of  the  cases  have  a 
history  of  either  epilepsy  or  insanity  in  the  family.  In  an  epi- 
leptic seizure  care  should  be  taken  that  the  child  does  not  injure 
himself.  The  nurse  should  watch  for  involuntary  passage  of 
urine  and  fasces,  as  this  often  occurs  in  epilepsy  and  may  be  an 
important  point  in  the  diagnosis. 

AIeningitis 

Meningitis  is  an  inflammation  of  the  membranes  covering 
the  brain,  most  commonly  affecting  the  pia  mater. 

Meningitis  may  be  caused  by  a  great  number  of  organisms, 
and  in  fact  is  frequently  secondary  to  infections  in  other  parts 
of  the  body. 

The  most  common  organisms  producing  meningitis  are :  the 
tubercle  bacillus,  influenza  bacillus,  pneumococcus,  staphylo- 
coccus and  streptococcus,  diplococcus  (meningococcus),  and 
Spirochcrta  pallida  (syphilitic  meningitis). 

Symptoms  of  a  beginning  meningitis  are  extremely  varied, 
depending  upon  the  character  and  severity  of  the  infection  and 
the  portion  of  the  brain  first  involved. 

Sooner  or  later,  in  addition  to  the  common  symptoms  of  infec- 
tion, indisposition  and  fever,  there  are  others  which  are  the  direct 
result  of  the  meningeal  condition,  such  as  vomiting,  headache, 
strabismus,  inequality  of  the  pupils,  rigidity  and  paralysis  of 
certain  groups  of  muscles  together  with  a  modification  of  the 
reflexes. 

CEREBROSPINAL  MENINGITIS   (MENINGOCOCCUS  MENINGITIS) 

This  form  occurs  occasionally  in  epidemics ;  the  majority  of 
cases,  however,  occur  sporadically.     This  is  the  one  form  of 


DISEASES  OF  THE  BRAIN 


227 


meningitis  for  which  we  now  have  a  specific  (Flexner's  serum), 
so  that  it  is  important  in  all  cases  to  be  able  to  say  definitely 
whether  we  are  dealing  with  the  meningococcus. 

Lumbar  Puncture. — In  order  to  determine,  it  is  necessary 
to  make  a  lumbar  puncture.     Some  fluid  is  drawn  from  the 


Fig.   108. — Lumbar  puncture. 

spinal  canal  and  the  character  of  the  infection  determined  by 
culture  and  microscopic  examination.  In  case  the  organism  is 
found  to  be  the  meningococctis,  Flexne/s  serum  should  be 
injected  at  once. 

Ti'XHNic. — A  lumbar  puncture  is   made  by  introducing  a 


228  CARE  OF  INFANTS  AND  CHILDREN 

needle  made  for  the  purpose  usually  between  the  fourth  and 
fifth  lumbar  vertebrae  (Figs.  io8).  The  entire  skin  at  the 
lower  third  of  the  back  and  extending  around  in  front  beyond 
the  crest  of  the  ilium  should  be  cleansed,  as  these  points  are  used 
by  the  operator  as  landmarks  in  locating  the  proper  place  for 
puncture. 

In  addition  to  sterile  needles,  several  sterile  test  tubes 
plugged  with  cotton  should  be  provided  to  catch  the  serum  which 
is  withdrawn. 

Flexner's  Serum. — Flcxner's  serum  is  usually  introduced 
through  the  same  needle.  The  amount  of  serum  introduced 
usually  depends  upon  the  amount  of  fluid  withdrawn.     This  is 


Fig.   109. — opisthotonos. 

introduced  daily,  until  the  symptoms  show  improvement.  When 
the  serum  is  used  early,  75  per  cent,  of  these  cases  recover.  The 
serum  is  absolutely  useless  in  all  other  forms  of  meningitis. 

Tuberculous  meningitis  is  practically  always  fatal.  The  mor- 
tality of  all  other  forms  is  high,  but  there  are  undoubtedly  a 
certain  per  cent,  of  recoveries. 

Infantile   Paralysis — Poliomyelitis 

Infantile  paralysis  is  now  recognized  as  an  acute  infectious 

disease,  characterized  by  more  or  less  general  symptoms  and  a 

tendency  to  attack  the  nervous  system,  often  producing  paralysis 

of  certain  muscles  or  groups  of  muscles.     The  disease  occurs 


DISEASES  OF  THE  BRAIN 


229 


sporadically,  but  during  the  past  few  years  it  has  been  occurring 
in  wide-spread  epidemics.  There  is  hardly  a  locality  in  this 
country  or  in  Europe  which,  during  the  past  ten  years,  has  not 
had  an  epidemic  of  this  disease. 

The  disease  shows  a  particular  disposition  to  attack  children 


Fig.  no. 


Fig.  111. 


Fig.  112. 


Fig.  110. — Drop-foot  resulting  from  infantile  paralysis. 

Fig.    111. — Detoripity  from  infantile  paralysis. 

Fig.  112. — Same  case  after  one  year's  treatment.  (Minnesota  Hospital  for  Crippled  and 

Deformed  Children.) 

under  three  years  of  age,  although  no  age  is  exempt.     "  There 
is  evidence  that  it  may  occur  during  intra-uterine  life." 

The  Organism  of  Poliomyelitis. — The  infectious  organism 
has  been  isolated  by  Flexner  and  is  described  by  him  as  a  minute 
globular  body  which  can  be  seen  only  by  the  highest  power 
microscope.  The  virus  is  communicated  from  one  person  to 
another  by  contact.  The  disease  may  be  spread  by  carriers,  some 
of  whom  have  been  themselves  previously  affected,  or  by  persons 
who  have  been  in  close  contact  with  the  disease.     The  organisms 


230  CARE  OF  INFANTS  AND  CHILDREN 

are  found  mostly  in  the  upper  air  passages.  In  the  majority  of 
the  epidemic  cases,  the  character  of  the  disease  is  not  known 
until  the  paralysis  appears.  The  general  symptoms  are  often 
those  of  an  influenza.  There  are  a  number  of  forms  described, 
depending  upon  which  portion  of  the  central  nervous  system  is 
particularly  attacked  by  the  disease.  In  an  epidemic,  combina- 
tions of  all  the  fonns  occur. 

For  the  paralysis  much  can  be  done  by  exercises  to  prevent 
.the  atrophy  of  the  muscles.  In  mild  cases  there  may  be  complete 
recovery  where  the  nerve  centres  have  not  been  destroyed. 
Massage  and  encouragement  to  use  the  muscles  so  far  as  possible 
'are  the  important  factors.  Later,  where  there  is  a  tendency  to 
contractions  of  the  opposing  muscles,  braces  and  other  appliances 
prescribed  by  the  orthopedist  are  of  great  benefit  in  preventing 
deformities  (Figs,  no,  in,  and  112). 

During  the  acute  stage  absolute  rest  should  be  enjoined. 
Massage  should  not  be  begun  before  the  sixth  week  from  the 
onset. 


CHAPTER  XXVII 
RHEUMATISM  AND  ST.  VITUS'S  DANCE 

Rheumatism 

Rheumatism  iii  children  is  much  more  common  than  was 
formerly  supposed.  By  rheumatism  I  mean  an  acute  inflamma- 
tion of  the  joints. 

It  is  now  regarded  as  an  infectious  disease,  due  to  some 
specific  organism,  in  all  probability  a  streptococcus. 

The  disease  is  frequently  secondary  to  other  inflammatory 
conditions,  such  as  scarlet  fever  and  tonsillitis.  In  recent  years, 
tonsillitis  has  been  popularly  regarded  as  the  common  cause  of 
rheumatism.  Recently,  decayed  and  abscessed  teeth  are  being 
also  regarded  as  a  possible,  if  not  a  frequent,  source  of  rheumatic 
as  well  as  other  general  infections.  The  symptoms  of  rheu- 
matism in  infants  are  often  not  so  pronounced  as  in  older  chil- 
dren and  adults.  The  involvement  of  the  joints  may  not  be  so 
general  and  the  temperature  not  so  high,  and  there  may  be  only 
one  or  two  joints  involved.  The  clinical  picture,  however,  is 
generally  quite  plain. 

Heart  Involvement. — The  frequency  with  which  the  heart 
becomes  afifected  in  rheumatism,  even  in  apparently  mild  cases, 
makes  it  a  serious  afifection.  In  many  cases  where  there  is  no 
apparent  heart  involvement  during  an  attack,  later  a  lesion  may 
be  found.  Too  frequently,  a  heart  lesion  is  discovered  when 
general  symptoms  of  broken  compensation,  shortness  of  breath, 
and  oedema  are  already  present.  Examinations  of  the  heart, 
therefore,  should  be  made  often,  and  the  child  taken  to  the 
physician  at  regular  intervals  for  at  least  a  year  after  the  last 
attack.  Qiildren  with  rheumatism  should  generally  be  kept  in 
bed  for  a  much  longer  period  than  seems  necessary  to  the  family. 
Duringthe  acute  stages  the  aflfected  joint  should  be  kept  at  perfect 
rest  and  wrapped  in  cotton  wool. 

231 


232  CARE  OF  INFANTS  AND  CHILDREN 

Salicylates. — For  local  medication,  wintergreen  oil  or 
some  of  the  salicylate  ointments  are  thought  to  be  of  benefit. 
When  salicylates  are  given  by  mouth,  they  frequently  cause 
derangement  of  the  digestion.  They  should  never  be  given  on 
an  empty  stomach,  and  always  well  diluted.  The  bowels  should 
be  kept  free  with  alkaline  laxatives,  such  as  Rochelle  salts,  and 
the  diet  should  be  of  a  simple  character  until  convalescence  is 
established.     Water  should  be  allowed  freely. 

Clothing. — The  clothing  should  be  of  woollen,  and  this 
should  be  maintained  even  during  the  summer  months,  when  the 
child  is  about,  because  of  a  marked  tendency  to  copious  sweating 
and  the  danger  of  subsequent  chill.  There  is  a  marked  tendency 
to  recurrence.  A  winter  spent  in  the  South,  on  the  sea-shore, 
where  the  children  may  be  out  of  doors  and  still  be  warm,  often 
works  wonders  in  these  cases  where  there  is  marked  debility. 

The  most  essential  points  in  the  prevention  are  the  discovery 
and  removal  of  the  portals  of  entry  of  the  infection. 

Chorea — St.  Vitus's  Dance 

"  Chorea  is  an  affection  of  the  central  nervous  system  ciiar- 
acterized  by  involuntary  incoordinate  movements  of  the  volun- 
tary muscles,  loss  of  power,  and  a  lack  of  control  of  the 
emotions.  There  is  a  tendency  to  complete  recovery."  But, 
unfortunately,  also  to  relapse. 

Although  the  disease  may  affect  children  of  any  age,  it  is 
most  common  between  the  ages  of  seven  and  fourteen  years.  It 
is  much  more  common  in  females  than  in  males. 

Relation  to  Rheumatism. — Although  the  cause  of  the  dis- 
ease is  not  known,  there  is  probably  a  close  relation  between  it 
and  rheumatism.  Of  1 1 1  cases  investigated  by  Crandall,  there 
was  a  definite  history  of  rheumatism  in  63. 

Affections  of  the  Heart. — ]\Tany  of  the  cases  suffer  from 
more  or  less  definite  involvement  of  the  joints  and  many  have  an 
accompanying  endocarditis. 


RHEUMATISM  AND  ST.  VITUS'S  DANCE  233 

Children  who  are  below  par  physically,  who  are  under- fed 
and  over-crowded  at  school,  are  particularly  liable  to  chorea. 
Chorea  may  follow  any  of  the  contagious  diseases  and  is  said 
to  be  frequently  associated  with  adenoids  and  large  tonsils. 
These  last,  however,  should  probably  be  regarded  only  as  pre- 
disposing causes. 

Symptoms. — The  first  symptoms  are  usually  attributed  to 
habit  or  simple  awkwardness.  The  child  has  difficulty  in  feeding 
itself,  drops  its  spoon,  fork  or  knife,  for  wdiich  it  is  usually 
scolded.  The  twitching  gradually  extends  in  severe  cases  to  all 
the  voluntary  muscles,  so  that  the  child  is  practically  helpless. 
Speech  is  often  interfered  with.  The  twitchings  are  increased 
by  excitement  and  fatigue,  but  do  not  continue  during  sleep. 
Children  with  chorea  are  irritable,  subject  to  fits  of  temper,  and 
are  liable  to  laugh  or  cry  often  without  "  rhyme  or  reason." 

Course. — An  attack  of  ordinary  severity  tends  to  recover  in 
from  six  to  ten  weeks.  It  may  last  for  months,  and  has  a 
tendency  to  recur. 

Trkatment. — The  nursing  of  these  cases  is  of  the  greatest 
importance.  They  should  be  removed,  if  possible,  from  the 
family,  and  particularly  from  the  other  children  in  the  family. 
They  should  be  taken  out  of  school,  and  all  other  work,  such  as 
music  lessons,  should  be  discontinued.  They  should  not  be 
scolded  or  ridiculed  on  account  of  the  irregular  movements,  but 
should  be  handled  firmly  and  not  allowed  to  impose  on  those  in 
attendance. 

Rest  in  bed,  a  maximum  of  plain,  nutritious  food,  removal 
from  all  worries  and  irritation,  with  the  gradual  resumption  of 
physical  exercise,  are  the  prominent  points  in  the  treatment  of 
chorea. 

Cases  of  great  severity  may  require  restraint,  hot  baths,  and 
sedative  drugs. 

Medication  in  the  form  of  tonics,  such  as  arsenic  and  iron, 
is  much  in  favor  with  many  physicians. 


234  CARE  OF  INFANTS  AND  CHILDREN 

Habit  Spasms 

There  are  spasmodic  movements  of  certain  muscles,  par- 
ticularly those  of  the  face,  occurring  usually  in  nervous  children, 
which  cannot  be  traced  to  any  diseased  condition  and  yet  are 
extremely  persistent  and  practically  beyond  the  control  of  the 
will.  These  twitchings  are  frequently  mistaken  for  chorea. 
They  sometimes  have  their  origin  in  a  local  irritation  in  the  con- 
junctiva or  in  the  mucous  membrane  of  the  nose,  the  twitching 
often  persisting  as  a  habit  spasm  after  the  original  cause  has 
quite  disappeared. 

It  is  important,  therefore,  at  once  to  ascertain  if  possible 
the  cause  of  any  irregular  muscular  movements,  for,  if  they 
once  become  fixed,  they  are  liable  to  continue  through  life. 


CHAPTER  XXVllI 
AFFECTIONS  OF  THE  HEART 

Affections  of  the  heart  are  extremely  common  in  children. 
Exclusive  of  the  congenital  conditions  already  described  (page 
i6),  there  are  a  variety  of  others,  both  functional  and  organic, 
which  are  of  varying  degrees  of  importance.  To  the  average  in- 
dividual any  heart  affection  means  "  heart  disease  "  and  "  heart 
disease  "  means  a  condition  which  sooner  or  later  ends  fatally, 
This,  of  course,  is  an  entirely  false  idea,  as  there  are  many 
affections  of  the  heart  which  are  purely  functional  in  character, 
and  still  others  which,  although  organic,  are  capable  of  perfect 
recovery. 

Functional  Murmurs. — During  the  rapid  growth  of  the 
child,  functional  heart  murmurs  are  common.  Following  the 
acute  infections,  heart  mumiurs  are  especially  common.  They 
may  be  functional  or  organic — many  times  it  is  impossible,  for 
the  time  being,  to  determine.  Whatever  the  character  of  the 
affection,  the  care  the  child  receives  will  often  determitie  whether 
the  recovery  will  be  complete  or  whether  th>;  child  will  go 
through  life  with  a  crippled  heart. 

Inflammatory  affections  of  the  heart  are  divided  into  three 
classes,  according  to  the  part  involved :  Endocarditis — an  in- 
flammation of  the  lining  membrane  of  the  heart,  including  the 
valves ;  myocarditis — an  inflammation  of  the  heart  muscle ; 
pericarditis — an  inflammation  of  the  serous  membrane  cover- 
ing the  heart  and  reflecting  back  upon  itself,  forming  the 
pericardial  sac. 

These  conditions  are  liable  to  occur  following  the  infectious 
diseases,  and  particularly  such  diseases  as  rheumatism,  scarlet 
fever,  diphtheria  and  measles.  In  acute  diseases  of  the  heart  the 
myocardium  is  practically  always  involved,  and  in  many  cases 
there  is  a  combination  of  all  three  forms. 

235 


236  CARE  OF  INFANTS  AND  CHILDREN 

Pekicakditis. — 111  pericarditis  the  pericardial  sac  may  become 
distended  with  fluid,  resulting  in  great  embarrassment  to  the 
heart  action.  Following  the  disappearance  of  the  fluid,  adhe- 
sions may  form  between  the  two  surfaces  of  the  pericardium, 
which  may  also  later  cause  serious  symptoms. 

Management. — Children  with  heart  affections,  whether 
functional  or  organic,  should  be  kept  under  proper  restraint. 
I  have  repeatedly  seen  children  with  heart  murmurs  which  were 
thought  to  be  organic  and  probably  permanent,  entirely  recover, 
with  careful  supervision  and  proper  restraint  from  over-exer- 
tion. On  the  other  hand,  even  children  with  organic  lesions  are 
coddled  too  much.  The  laying  out  of  a  regime  for  these  chil- 
dren requires  absolute  co-operation  between  physician,  nurse, 
and  family. 

It  is  of  little  use  to  send  children  ofif  to  play  with  other 
healthy  children  and  caution  them  not  to  over-exercise.  One 
might  as  well  tell  the  wind  not  to  blow.  The  only  way  to  get 
results  in  these  cases  is  to  have  them  constantly  watched ;  other- 
wise many  of  them  will  be  permanently  crippled  who  would 
otherwise  recover. 

In  children  with  well-defined  valvular  lesions,  their  sojourn 
on  earth  will  depend  largely  upon  the  care  which  is  taken  of  the 
heart  muscle.  These  hearts  are  always  hard  worked,  and  if  an 
extra  amount  of  work  is  thrown  upon  them  the  compensation 
breaks  down  and  the  child  soon  succumbs.  If,  on  the  other 
hand,  these  children  are  allowed  only  enough  exercise  to  keep 
them  in  good  physical  condition,  they  may  live  useful,  happy  lives 
for  many  years  and  finally  die  from  some  other  cause. 

The  first  essential  in  the  treatment  of  all  acute  organic  heart 
aflfections  is  rest  in  the  horizontal  position,  the  time  to  be  de- 
termined by  the  physician  in  charge.  The  mistake  is  usually 
made  of  allowing  children  with  heart  affections  to  get  about  too 
soon. 

The  heart  complication?  of  the  contagious  diseases  will  be 
considered  in  that  connection. 


CHAPTER  XXIX 
AFFECTIONS  OF  THE  SKIN 

Diseases  of  the  skin  are  divided  by  Adamson  into  four 
classes:  (i)  eruptions  due  mainly  to  physical  causes;  (2) 
eruptions  of  parasitic  or  microbic  origin;  (3)  toxic  eruptions 
and  eruptions  of  unknown  origin;     (4)    congenital   affections. 

It  is  always  difficult  to  keep  this  classification  distinct  one 
from  the  other,  since  not  infrequently  the  presence  of  one  oper- 
ates as  a  predisposing  ele- 
ment in  producing  another. 

Eczema  and  the  Exuda- 
tive Diathesis 

Eczema  is  a  common  af- 
fection in  infants  and  chil- 
dren of  all  ages.  The  con- 
dition known  to  the  laity 
as  milk  crusts  is  a  com- 
mon one  in  young  babies, 
many  of  which  are  breast- 
fed.' 

The  exudate  usually  be- 
gins on  the  scalp  as  a  scaly 
condition  resembling  dirt. 
If,  however,  an  attempt  is 
made  to  remove  the  scales  with  soap  and  water,  or  by  vigorous 
rubbing,  it  will  be  found  that  the  underlying  skin  is  red,  and 
after  a  few  minutes  has  small  drops  of  serum  scattered  over  the 
surface.  These  soon  become  dry,  forming  small  crusts  (Fig.  113). 
If  the  process  of  removing  is  persisted  in,  or  if  the  child  is  allowed 
to  scratch — which  it  will  do  if  it  can,  as  the  condition  is  extremely 

237 


Fig.   ll-i. — Eczema  of  scalp  with  formation  of 
crusts. 


238 


CARE  OF  INFANTS  AND  CHILDREN 


itchy — the  crusts  become  thicker  and  more  general,  spreading 
often  to  the  forehead  and  cheeks  and  later  to  the  hands,  body, 
and  lower  extremities.  In  many  cases  the  exudate  begins  on  the 
face  and  never  afifects  the  scalp.  After  a  time  the  serum  under 
the  crusts  becomes  infected  with  pus  cocci,  and  there  is  added 
to  the  eczema  a  pus  infection,  resulting  often  in  a  general 
Impetigo  contagiosa  (Fig.  114).  Owing  to  the  pus  infection 
there  is  often  considerable  fever,  and  the  superficial  glands, 
particularly  the  cervical,  are  liable  to  be  much  enlarged. 

In  most  of  these  cases  there  is  an  underlying  constitutional 
condition  known  as  exudative  diathesis.     These  children  have  a 

condition  of  the  blood  in 
which  the  eosinophile  cells 
are  greatly  in  excess  of  the 
normal.  After  the  exudate 
has  entirely  disappeared 
from  the  skin  in  these  cases 
it  reappears  again  and  again, 
many  times  without  any  ap- 
parent provocation.  O  v  e  r  - 
feeding,  particularly  with  fat, 
frequently  results  in  an  acute 
exacerbation,  which  is  liable 
to  persist,  in  spite  of  all  local 
treatment,  until  the  fat  has  been  reduced. 

Treatment. — The  successful  treatment  of  these  cases,  there- 
fore, must  be  both  local  and  constitutional.  An  important 
feature  in  the  local  treatment  is  to  get  the  skin  free  from  pus 
and  then  keep  it  clean.  When  the  scalp  is  covered  with  crusts 
from  which  pus  oozes  upon  pressure,  the  crusts  must  be 
removed,  and  the  best  way  is  by  large  dressings  of  normal 
salt  solution,  which  are  kept  on  until  the  scalp  is  free  from 
crusts  and  any  evidence  of  pus.  The  character  of  the  medication 
will  have  to  be  determined  by  the  physician  in  charge.  Whatever 
the  medication,  the  object  is  to  keep  the  skin  clean  and  free  from 


Fig.    114. — Impetigo  contagiosa. 


AFFECTIONS  OF  THE  SKIN 


239 


irritation,  until  healed.  To  do  this,  scratching  and  rubbing  must 
be  prevented.  The  condition  is  extremely  itchy  and  the  child  has 
an  uncontrollable  desire  to  scratch  the  affected  skin.  The  hands 
will  have  to  be  restrained.  Splints  applied  to  each  arm,  prevent- 
ing the  child  from  bending  the  elbow,  will  allow  considerable 
freedom  but  prevent  scratching  the  face.  A  simple  form  of 
splint  is  a  pasteboard  tube  limiting  the  motion  of  the  elbow. 
Hand  mittens  may  be  worn. 

The  most  difficult  thing 
is  to  prevent  the  baby  from 
rubbing  its  face  or  head  in 
the  pillow  or  against  any- 
thing which  is  available. 
A  mask  made  from  some 
fabric  such  as  linen  or  cot- 
ton (Fig.  115)  may  often 
have  to  be  applied.  An 
ideal  protection  would  be 
furnished  by  a  mask  re- 
sembling a  base-ball  mask, 
made  of  wire,  which  would 
admit  of  perfect  cleanliness 
and  protection,  a  condition 
wofully  lacking  in  the  or- 
dinary cloth  mask. 

Cleanliness. — Children  of  the  exudative  type  are  par- 
ticularly prone  to  eruptions  of  the  skin  under  the  diaper,  which 
is  irritated  by  contact  with  the  urine  and  stool.  These  eruptions 
are  of  various  characters  and  intensity  and  may  frequently  be 
complicated  by  infections  from  the  skin  organisms.  To  prevent 
such  irritation  the  diapers  should  be  changed  as  soon  as  soiled 
and  the  skin  washed  and  powdered,  and  some  simple  ointment, 
such  as  oxide  of  zinc,  used  to  protect  the  skin.  These  children 
are  also  prone  to  have  eruptions  in  the  folds  of  the  skin,  under 
the  chin,  behind  the  ears,  under  the  arms,  unless  these  folds  are 


Fig.   115.- 


Face   mask  and   arm   splints   for   the 
treatment  of  eczema. 


240  CARE  OF  INFANTS  AND  CHILDREN 

kept  scrupulously  clean  and  free  from  secretions.  Soaps  should 
be  used  as  little  as  possible  in  these  cases.  The  irritated  parts 
should  be  washed  with  water  to  which  some  borax  has  been  added 
and  then  gently  sponged  dry,  and  a  little  stearate  of  zinc,  or 
starch  powder,  dusted  over  the  surface.    ■ 

Hives — Urticaria  or  Nettle-rash 

Urticaria  is  due  either  to  some  local  irritation  of  the  skin  or 
to  the  ingestion  of  some  toxic  substance  in  the  food,  or  to  certain 
medicinal  agents,  particularly  diphtheria  antitoxin,  causing  a 
dilation  of  the  capillaries  in  the  skin  and  the  production  of  wheals 
or  raised  blotches.  The  most  common  cause  is  probably  the 
eating,  in  susceptible  individuals,  of  such  foods  as  strawberries, 
eggs,  or  shell-fish.  The  rash  is  more  or  less  general  and  usually 
is  accompanied  by  intense  itching.  Whenever  pressure  is  made 
upon  the  skin,  a  red  raised  line  appears  in  a  few  seconds,  which 
may  remain  for  several  hours  before  it  gradually  disappears. 

PREVENTioN.-^Wheh  children  are  known  to  have  an 
idiosyncrasy  to  certain  foods  these  in  the  future  should  be 
avoided. 

For  the  active  condition  a  thorough  catharsis  with  castor  oil 
or  some  other  simple  cathartic,  and  a  diet  for  several  days  con- 
sisting largely  of  starchy  food  in  some  form,  should  be  given. 

For  the  intense  itching,  soda  baths,  or  the  application  of 
carbolized  vaseline  in  small  quantities,  will  sometimes  give  relief. 
Where  the  itching  is  persistent  in  very  nervous  children,  some 
sedative  may  have  to  be  given  until  the  toxic  substances  have 
been  eliminated  and  the  nervous  system  returns  to  the  normal. 

Chilblains 
Chilblain  is  another  common  affection  in  children.  It 
occurs  on  the  extremities,  most  frequently  the  feet,  as  a  result 
of  exposure  to  cold.  Some  children  are  particularly  susceptible 
to  chilblains  and  suffer  from  intense  itching  during  the  entire 
winter,  unless  the  feet  are  kept  warm  by  warm  stockings  and 
overshoes.     Tight  shoes  should  be  particularly  avoided. 


AFFECTIONS  OF  THE  SKIN  241 

Birthmarks — N.evi 

The  term  "  naevus  "  is  used  in  dermatology  to  indicate  all 
congenital  localized  overgrowths  of  any  of  the  elements  of  the 
skin.  The "  most  common  varieties  are  the  vascular  moles  or 
pigmented  tucvi,  and  the  port-wine  mark,  besides  many  mixed 
forms. 

The  origin  of  birthmarks  is  unknown,  but  they  probably  have 
no  connection  with  "  maternal  impressions."  Many  of  the  naevi 
are  innocent,  but  some  of  the  vascular  forms  have  a  marked 
tendency  to  spread.  Under  such  conditions  they  should  be  radi- 
cally destroyed  by  cauterizing  with  carbon  dioxide  snow,  actual 
cautery,  or  by  excision.  Innocent  small  ones  may  be  removed 
for  cosmetic  reasons.  The  large  wine-colored  spots  are  usually 
impossible  of  removal. 

The  following  is  a  list  of  other  skin  affections  occurring  in 
children : 

1.  Eruptions  due  to  animal  parasites,  such  as  scabies  (itch)  ; 
pediculosis  capitis  (head  lice)  ;  eruptions  due  to  fleas,  mos- 
quitoes, spiders,  ants,  etc. 

2.  Fungous  infections,  such  as  ringfworm  and  favus.    . 

3.  Microhic  infections,  such  as  impetigo  contagiosa,  bullous 
impetigo,  dermatitis  gangraenosa,  dermatitis  exfoliativa,  tuber- 
culosis of  the  skin  (lupus  vulgaris),  acne,  eruptions  of  congenital 
syphilis. 

4.  Toxic  eruptions:  herpes  febrilis,  herpes  zoster,  erythema 
nodosum,  erythema  multiforme. 

5.  Drug  eruptions. 

6.  Vaccination  eruptions. 

7.  Eruptions  of  unknoum  origin,  as  pemphigus,  psoriasis, 
pityriasis,  scleroderma,  alopecia  (some  forms). 

For  a  description  of  the  above  named  diseases,  together  with 
any  others,  the  reader  is  referred  to  a  standard  work  on  diseases 
of  the  skin  (Stellwagen  or  Crocker).  The  important  thing  for 
the  nurse  is  to  be  able  to  recognize  and  isolate  the  contagious 
forms. 
lb 


242  CARE  OF  INFANTS  AND  CHILDREN 

Vaccination 

In  order  to  render  children  immune  from  the  infection  of 
smallpox,  they  are  inoculated  with  the  cowpox  (vaccinia). 
Formerly  much  of  the  virus  was  obtained  from  other  children 
who  had  been  vaccinated.  It  was  found,  however,  that  by  this 
means  such  diseases  as  syphilis  could  be  transmitted  from  one  to 
another. 

Source. — The  virus  is  now  obtained  from  an  extensive  vac- 
cination of  the  flanks  of  healthy  calves,  the  utmost  precaution 
being  taken  to  insure  against  any  possible  disease,  such  as  anthrax 
or  tetanus.  All  vaccine  is  tested  on  animals  for  possible  patho- 
genic organisms,  and  the  calves  are  killed  and  examined  before 
the  vaccine  is  put  upon  the  market.  The  vaccine  is  mixed  with 
glycerine  and  put  up  in  capillary  tubes,  or  on  sterile  celluloid  or 
glass  points. 

Time  for  Vaccination. — Children  should  be  vaccinated  as 
a  rule  during  the  first  six  months.  There  is  usually  less  reaction 
in  a  young  child  than  at  a  later  age. 

Repetition. — The  vaccination  should  be  repeated  every  six 
or  seven  years,  and  oftener  if  smallpox  is  epidemic.  Infants  who 
are  suffering  from  an  extensive  eczema  should  not  be  vaccinated 
until  they  are  well,  as  an  extensive  vaccination  eruption  may 
occur  over  the  entire  body,  such  as  I  saw  in  one  case  abroad,  with 
fatal  result  (Fig.  ii6). 

Location. — Boys  are  usually  vaccinated  on  the  left  arm  at 
about  the  insertion  of  the  deltoid  muscle. 

Girls,  for  cosmetic  reasons,  should  be  vaccinated  on  the  leg, 
the  outer  aspect  of  the  calf  being  the  usual  point  chosen. 

The  skin  should  be  washed  with  water  and  soap  and  then  with 
ether.  If  alcohol  is  used  the  chances  are  less  for  a  good  "  take." 
It  should  be  thoroughly  dried,  as  any  alcohol  which  may  remain 
is  liable  to  destroy  the  virus. 

Tech  NIC — The  skin  is  then  scratched  with  a  sterile  needle 
or  "  point  "  until  the  epithelium  is  removed  and  the  wound  begins 


AFFECTIONS  OF  THE  SKIN  243 

to  bleed.  The  vaccine  should  then  be  thoroughly  worked  in  with 
the  point  or  a  sterile  toothpick.  A  new  method  described  by  Dr. 
W.  H.  Hill  consists  in  thoroughly  cleansing  the  skin,  as  described 
above.  A  small  drop  of  vaccine  is  then  placed  on  the  skin  in  the 
desired  place,  and  a  number  of  superficial  punctures  of  the  upper 


Fig.   116. — General  vaccination  in  a  child  with  eczema. 

layers  of  the  skin  are  made  with  a  sterile  needle  through  the 
vaccine.  The  shield  is  then  applied  as  above.  The  advantage 
of  this  method  is  the  small  chance  of  a  mixed  infection.  The 
vaccine  should  be  allowed  to  dry  and  then  be  covered  with  sterile 
gauze  or  shield.  After  four  to  six  days  a  red  papule  appears. 
This  is  rapidly  changed  to  a  vesicle.     There  is  an  area  of  redness 


244  CARE  OF  INFANTS  AND  CHILDREN 

which  gradually  extends  around  the  vesicle  until  it  reaches  the 
size  of  a  silver  dollar,  or  larger.  The  lymphatic  glands  in  the 
axilla  or  groin  are  liable  to  be  considerably  enlarged.  For  the 
first  few  days  after  the  vesicle  begins  to  form,  there  is  a  general 
feeling  of  malaise,  and  often  considerable  fever.  There  may 
be  a  general  rash ;  this  is  sometimes  a  general  erythema  or  is 
more  often  blotchy  in  character.  After  a  few  days  it  gradually 
fades  and  the  general  symptoms  disappear.  If  the  vaccination  is 
performed  on  the  leg,  the  local  and  general  symptoms  are  liable 
to  be  more  severe. 

The  vaccination,  if  clean,  after  a  week  gradually  dries,  form- 
ing a  scab,  the  redness  fades,  and  after  a  few  weeks  the  scab  falls 
off,  leaving  a  permanent  scar. 

The  important  point  in  the  care  of  a  vaccination  vesicle  is  to 
keep  it  from  becoming  infected.  The  dressing  or  shield  should 
be  removed  daily,  after  the  vesicle  is  formed,  and  the  whole  area 
washed  with  alcohol  and  the  sterile  dressing  reapplied. 

If  good  vaccine  is  used,  and  if  care  and  cleanliness  are  exer- 
cised in  its  use,  there  will  be  no  serious  results  from  vaccination. 
If  the  vaccination  does  not  "take"  within  ten  days  the  child 
should  be  re-vaccinated. 


CHAPTER  XXX 

THE  INFECTIOUS  DISEASES 

The  old  group  of  infectious  diseases  was  comparatively  small. 
It  has  gradually  been  added  to,  so  that  now  it  includes  practically 
all  of  the  febrile  diseases.  There  is,  however,  a  certain  group 
of  infections  to  which  children  are  peculiarly  susceptible  which 
are  communicated  from  one  to  the  other.  Most  of  this  group  are 
subject  to  some  degree  of  quarantine  by  the  different  boards  of 
health.  The  diseases  which  will  be  considered  in  this  group 
are  the  following:  scarlet  fever,  measles,  German  measles, 
diphtheria,  whooping-cough,  mumps,  chicken-pox,  smallpox, 
erysipelas,  tuberculosis,  syphilis. 

QUAR.\NTINE 

Quarantine  formerly  meant  isolation  for.  forty  days.  It  is 
now  a  term  used  to  signify  isolation  for  any  length  of  time,  and 
may  be  partial  or  complete. 

Outside  of  institutions  for  the  care  of  contagious  diseases, 
most  of  the  quarantine  is  partial.  The  child  is  isolated  so  far 
as  possible  and  the  father  and  other  older  members  of  the  family 
are  permitted  to  go  to  their  work. 

If  a  trained  nurse  is  employed,  and  the  arrangement  of  the 
rooms  is  anything  like  ideal,  a  fairly  efficient  quarantine  may  be 
maintained. 

By  a  proper  working  knowledge  of  the  character  and  habits 
of  the  different  organisms,  and  the  manner  by  which  they  are 
communicated  from  one  person  to  another,  an  efficient  quaran- 
tine may  be  maintained  in  certain  diseases  without  materially 
interfering  with  the  necessary  routine  of  the  household  or  in 
keeping  the  bread-winner  from  his  work. 

For  example,  it  has  been  demonstrated  in  several  contagious 
hospitals  that  scarlet  fever  and  diphtheria  may  be  treated  in  the 

245 


246  CARE  OF  INFANTS  AND  CHILDREN 

same  ward,  the  patients  being  separated  by  partitions  in  the 
form  of  stalls,  if  the  attendants  exercise  the  proj>er  care  as  to 
cleanliness,  without  any  cross  infection  taking  place. 

Milk  as  a  SouKCii  of  Infection. — The  old  idea  that  the 
common  way  for  infection  to  travel  was  by  the  air  from  house 
to  house  has  been  recently  disproven.  It  has,  however,  been 
proven  that  a  common  source  of  infection  in  a  neighborhood  is 
the  milk-wagon  which  distributes  infected  milk,  frequently  re- 
ceiving infected  empty  bottles  in  return  and  taking  them  back  to 
be  refilled  and  redistributed  without  proper  sterilization. 

It  is  improbable  that  any  of  the  infectious  agents  are  carried 
any  great  distance  through  the  air,  but  are  limited  to  fairly  close 
proximity  to  the  infected  persons. 

The  common  means  by  which  disease  is  spread  are  the 
following: 

1.  Close  contact  with  an  infected  person. 

2.  By  means  of  dishes  or  other  utensils  used  by  an  infected 
person. 

3.  By  means  of  a  third  person  who  has  come  in  such  close 
contact  with  an  infected  person  as  to  permit  the  infectious 
material  to  adhere  to  the  clothing. 

4.  By  means  of  infected  food  or  water. 

5.  Carriers — persons  who,  although  not  sick  themselves,  may 
harbor  infectious  organisms. 

6.  Insects,  particularly  flies  and  vermin. 

7.  Domestic  animals — dogs  and  cats. 

Care  of  Clothing  and  Utensils. — In  caring  for  a  child 
with  a  contagious  disease,  the  simplest  washable  clothing  only 
should  be  worn.  The  sleeves  of  the  dress  and  outer  gown  or 
apron  should  not  reach  below  the  elbow.  If  a  nurse  has  charge 
of  more  than  one  patient,  there  should  be  a  separate  gown  for 
each — unless  both  have  the  same  disease.  Each  patient  should 
have  his  own  complete  outfit  of  utensils.  The  thermometer 
should  be  kept  in  a  strong  solution  of  carbolic  acid  or  some  other 
powerful  antiseptic,  it  first  having  been  thoroughly  washed.     I 


THE  INFECTIOUS  DISEASES  247 

have  recently  found  pure  culture  of  streptococci  on  several 
clinical  thermometers  which  had  been  used  in  the  mouth  of  an 
erysipelas  case,  and  this  after  they  had  been  washed  in  water 
and  then  in  alcohol. 

All  dishes  should  be  boiled  before  being  sent  to  the  kitchen. 
]\Iilk  bottles  should  not  be  admitted  in  the  sick-room.  The  milk 
should  preferably  be  transferred  to  a  sterile  covered  receptacle 
and  boiled  or  pasteurized  and  then  placed  on  the  ice  until  used. 
If  milk  bottles  are  admitted  to  the  house  they  should  always  be 
boiled  before  returning  to  the  dairy. 

Clothing  which  has  come  in  contact  with  the  patient  should 
be  thoroughly  carbolized  or  lysolized  in  a  2  per  cent,  solution, 
or  subjected  over  night  to  a  i-iooo  formalin  solution,  after 
which  it  should  be  sent  to  the  laundry  and  boiled.  Handker- 
chiefs are  particularly  liable  to  be  soiled  with  infectious  material. 
For  this  reason  it  is  more  practical  to  use  cheese-cloth,  which  can 
be  burned. 

Excreta. — All  the  excreta  from  the  patient,  urine,  fasces, 
and  sputum,  usually  contain  infectious  material,  which  should 
be  destroyed  by  carbolization  before  being  put  into  the  closet. 

Care  of  the  Hands. — The  hands  of  the  nurse  should  be 
washed  thoroughly  with  soap  and  water  each  time  the  patient 
is  handled.  The  continuous  use  of  strong  antiseptics  on  the 
hands  is  liable  in  the  long  run  to  do  more  harm  than  good,  as 
this  destroys  the  upper  layer  of  the  skin  which  serves  to  harbor 
bacteria. 

In  the  actual  handling  of  erysipelas  and  scarlet  fever  where 
the  streptococci  are  omnipresent,  rubber  gloves  should  be  worn. 
They  should  be  sufficiently  large  as  to  be  slipped  on  and  off 
without  difficulty. 

There  are  certain  requisites  for  rooms  in  Which  a  patient  is 
to  be  quarantined. 

They  should  be  as  far  removed  from  the  living-rooms  as 
possible,  preferably  on  the  top  floor.  They  should  be  comfort- 
able, with  plenty  of  windows  and  direct  sunlight.     There  should 


248  CARE  OF  INFANTS  AND  CHILDREN 

be  a  bathroom  in  connection,  to  be  used  exclusively  by  the  patient 
and  the  nurse.  A  wood  stove  is  almost  indispensable  in  such  a 
sick-room,  even  if  the  rooms  are  heated  by  a  central  heating 
plant.  It  acts  as  an  excellent  ventilator,  infected  rags,  etc.,  may 
be  burned,  water  may  be  boiled  for  scalding  and  washing  dishes,, 
bathing,  and  an  endless  variety  of  other  things.  An  open  fire- 
place is  an  excellent  adjunct  to  any  such  room  but  it  will  not,  in  a 
quarantined  apartment,  take  the  place  of  a  wood  stove. 

The  time  of  quarantine  is  variable  and  will  differ  with  the 
disease. 

Protection  of  the  Nurse  Against  Infection. — While  in 
quarantine  nurses  should  take  every  means  to  protect  themselves 
against  infection.  While  swabbing  the  throat  of  a  child  infected 
with  diphtheria  or  scarlet  fever,  a  nurse  should  always  take  the 
precaution  to  wear  a  pair  of  large  glasses  to  protect  the  eyes,  and 
a  mask  of  gauze,  such  as  surgeons  use  in  operating,  over  the  nose 
and  mouth.  If  nurses  take  such  precautions  they  would  not  so 
often  be  themselves  victims  of  these  diseases,  nor  when  relieved 
from  quarantine  act  as  carriers  to  infect  others. 

It  must  be  remembered  that  two  or  more  of  the  contagious 
diseases  may  exist  in  the  same  patient  at  the  same  time.  In  a 
considerable  proportion  of  cases  diphtheria  bacilli  are  present  in 
the  throats  of  scarlet  fever  patients  and  may  become  active. 

In  contagious  hospitals  a  certain  amount  of  cross-infection 
is  inevitable  unless  the  most  rigid  precautions  are  taken. 

Scarlet  Fever 

Scarlet  fever  is  an  acute  contagious  disease  characterized  by 
sudden  onset  with  vomiting,  fever  and  sore  throat  (angina),  and 
the  appearance  usually  within  twenty-four  hours  of  a  character- 
istic rash. 

Streptococci  1  are  practically  always  present  in  the  throat 
and  are  probably  the  cause  of  the  angina  and  enlarged  glands,  as 

lA  form  of  streptococcus  known  as  the  beta  form  isolated  by  Dr. 
Theobald  Smith  and  others. 


THE  INFECTIOUS  DISEASES  249 

well  as  of  the  middle-ear  and  kidney  complications  which  so 
often  occur  in  the  course  of  this  disease.  One  attack  of  the 
disease  usually  renders  the  person  immune  for  life. 

Incubation. — The  period  of  incubation  (that  is,  the  time 
which  elapses  after  exposure  until  the  first  symptoms  appear) 
varies  from  one  to  nine  days. 

Presence  of  the  Streptococcus  in  the  Throat. — The 
specific  organism  is  still  unknown.  The  fact  that  the  strepto- 
coccus is  practically  always  present  in  the  throat  has  led  many 
observers  to  believe  that  this  organism  may  be  the  specific  cause. 

Means  of  Dissemination. — Whatever  the  specific  organism 
or  poison,  it  is  extremely  tenacious  and  has  been  known  to  remain 
in  clothing  for  years  and  then  produce  the  disease  in  a  susceptible 
individual.  Until  recently  it  has  been  thought  that  the  disease 
was  chiefly  carried  by  means  of  the  scales  during  the  period  of 
desquamation.  Whether  the  scales  in  themselves  are  infectious 
it  is  not  definitely  known.  That  the  discharges  from  the  nose, 
throat  and  also  the  ears,  if  there  is  a  middle-ear  involvement,  are 
extremely  infectious  there  is  no  doubt  It  is  probable  that  these 
are  the  chief  sources  of  infection. 

Quarantine. — The  boards  of  health  have  kept,  and  still  do 
keep,  scarlet  fever  cases  quarantined  until  they  are  through 
scaling,  with  the  minimum  of  three  weeks.  This  may  or  may  not 
be  sufficient.  If  a  child  has  a  purulent  discharge  from  the  nose 
or  ear,  it  should  not  mix  with  other  children  as  long  as  the  dis- 
charge continues.  After  a  child  is  released  from  quarantine  it 
is  always  a  wise  precaution  to  keep  him  from  close  contact  with 
other  members  of  the  family  for  as  long  a  time  as  possible. 
Kissing  and  the  use  of  the  same  towels  should  be  especially 
prohibited. 

Course. — There  is  probably  none  of  the  infectious  diseases 
in  which  the  course  varies  so  greatly  as  in  scarlet  fever.  The 
child  may  be  intensely  sick  from  the  onset,  the  temperature  high, 
the  throat  swollen,  oedematous  and  covered  with  a  necrotic  mem  - 
brane,  the  glands  of  the  neck  swollen  and  tender,  and  after 
twenty-four  hours  there  may  be  an  intense  rash  covering  the 


250  CARE  OF  INFANTS  AND  CHILDREN 

entire  body.  In  such  a  case  the  poisoning  may  be  so  severe  that 
death  results  within  the  first  few  days. 

P'rom  such  an  extreme  as  the  above,  there  are  all  grades,  to 
that  in  which  it  is  impossible  to  say  whether  the  case  is  really 
scarlet  fever. 

In  most  of  the  cases,  and  even  the  mild  ones,  there -is  a  char- 
acteristic appearance  of  the  tongue — "  strawberry  tongue."  This 
condition  follows  the  desquamation  of  the  upper  layers  of 
epithelium,  leaving  the  surface  red  and  the  papillae  prominent. 
Even  when  the  rash  is  most  intense  over  the  whole  body,  there  is 
always  a  relatively  pale  area  around  the  mouth. 

Desquamation. — In  the  severe  cases,  the  desquamation  of 
the  skin  begins  on  the  neck  and  face  even  before  the  rash  has 
disappeared  from  the  rest  of  the  body.  In  such  cases  the  skin 
of  the  hands  and  feet  may  be  exfoliated  in  the  form  of  casts. 
This,  however,  is  very  unusual.  In  the  milder  cases  the  desqua- 
mation of  the  body  may  be  difficult  to  detect,  and  it  is  only  after 
two  or  three  weeks,  when  the  palms  of  the  hands  and  soles  of  the 
feet  begin  to  "  peel,"  that  a  positive  diagnosis  is  possible. 

It  is  these  mild  cases  which  so  frequently  serve  to  spread  the 
disease.  They  often  go  unrecognized  and  are  sent  to  school  as 
usual. 

All  cases  in  which  there  is  a  sore  throat  associated  with  a  rash 
and  strawberry  tongue  should  be  diagnosed  as  scarlet  fever  and 
isolated,  at  least  for  a  time. 

Complications. — The  most  common  complications  in  scarlet 
fever  are  the  following : 

1.  Infection  of  the  glands  of  the  neck  (adenitis).  This  may 
be  so  severe  as  to  break  down  and  form  abscesses,  which  may 
have  to  be  opened  and  drained. 

2.  Abscess  of  the  middle  ear,  sometimes  including  the 
mastoid. 

3.  Acute  nephritis. 

4.  Acute  pericarditis  and  endocarditis. 

5.  Multiple  arthritis. 


THE  INFECTIOUS  DISEASES  251 

Care  of  the  Nose  and  Throat. — With  severe  infections  of 
the  throat  and  nose,  some  mild  non-irritating  antiseptic,  such  as 
argyrol  ( 10  to  20  per  cent,  solution),  may  be  frequently  dropped 
in  the  nose,  with  the  head  well  back,  so  that  it  will  run  into  the 
throat.  If  there  is  much  purulent  discharge  the  nose  and  throat 
should  be  irrigated  with  normal  salt  solution  by  tipping  the  head 
well  forward  and  allowing  the  solution  to  go  in  one  nostril  and 
out  of  the  other.  The  mouth  and  teeth  should  be  kept 
scrupulously  clean  with  some  mild  antiseptic  solution,  such  as 
Seiler's  or  Dobell's. 

Under  no  circumstances  should  fluid  be  introduced  into  the 
nose  under  pressure,  on  account  of  the  danger  of  forcing  in- 
fectious material  into  the  middle  ear. 

An  ice-bag  should  be  kept  fairly  constantly  applied  over  the 
enlarged  glands  in  the  neck,  and  if  they  break  down  they  should 
later  be  opened. 

The  Urine. — The  urine  in  scarlet  fever  should  be  sent  regu- 
larly to  the  physician  for  examination  and  the  daily  quantity 
measured. 

When  there  is  any  heart  involvement,  absolute  rest  in  bed 
should  be  insisted  upon.  If  all  cases  of  scarlet  fever,  even  mild 
cases,  were  kept  in  bed  for  two  or  three  weeks,  there  would  be 
less  permanent  disability  of  the  heart  and  kidneys. 

Diet. — During  the  acute  period  of  the  disease  the  food  should 
be  extremely  light,  consisting  chiefly  of  boiled  milk  diluted  with 
water,  or,  better,  buttermilk  and  carbohydrates.  During  this 
time  copious  draughts  of  water  should  be  given  ;  weak  lemonade 
or  orangeade  is  an  excellent  substitute. 

The  bowels  should  be  kept  open  daily,  if  necessary  with  a 
simple  enema,  and  when  the  desquamation  begins  the  skin  should 
be  anointed  daily  with  oil. 

Measles 
Measles  is  the  most  common  of  the  eruptive  fevers.     It  is 
highly  contagious  and  occurs  in  such  wide-spread  epidemics  that 


252 


CARE  OF  INFANTS  AND  CHILDREN 


it  is  rare  that  a  child,  in  the  city  at  least,  reaches  the  age  of 
adolescence  without  having  had  the  disease. 

The  specific  cause  of  measles  is  unknown,  hut  the  infectious 
poison  is  given  off  in  the  hreath  and  is  spread  further  by  means 
of  the  air  than  almost  any  of  the  other  forms.  The  poison,  how- 
ever, is  soon  destroyed  and  "does  not  persistently  cling  to  clothing 
and  dwelling  rooms,  as  does  scarlet  fever." 

Initial  Symptoms. — Measles  has  an  incubation  period  of 
from  12  to  14  days.  Then  begin  the  initial  symptoms,  lasting 
from  three  to  five  days,  during  which  time  the  child  has  slight 
fever,  gradually  increasing,  with  beginning  cough,  sneezing  and 
redness  of  the  conjunctivae. 

The  Rash. — At  the  end  of  the  initial  period  the  cough  is 
usually  dry  and  persistent,  the  eyes  red  and  sensitive  to  light, 
and  a  characteristic  blotchy  rash  appears,  first  on  the  face  and 
neck,  gradually  spreading  to  the  body  and  extremities.  In  a 
large  percentage  of  the  cases,  as  long  as  two  or  three  days  before 
the  rash  appears  on  the  skin,  there  may  be  evidence  of  the  disease 
on  the  mucous  membranes  of  the  mouth  in  the  form  of  tiny  white 
flecks  on  a  red  base,  known  as  "  Koplik's  spots."  The  rash  per- 
sists for  from  four  to  six  days,  gradually  disappearing  in  the 
order  in  which  it  came. 

Contagious  Character. — The  disease  is  contagious  from 
the  onset  of  the  catarrhal  symptoms,  a  fact  which  makes  a  suc- 
cessful quarantine  difficult  if  not  impossible  in  many  cases.  Few, 
if  any,  children  are  naturally  immune,  although  very  young  in- 
fants during  the  first  year  do  not  acquire  it  so  readily. 

Temperature. — During  the  period  in  which  the  rash  is 
coming  out,  the  temperature  is  usually  the  highest,  often  reaching 
104°  F.  on  the  second  day  of  the  eruption.  When  the  rash  is 
fully  out,  the  temperature  begins  to  recede  and  the  cough  usually 
becomes  less  troublesome.  During  this  time  the  eyelids  may  be 
stuck  together  with  secretion.  This  may  be  prevented  by  smear- 
ing the  margins  of  the  lids  with  vaseline.  There  is  also  a  marked 
burning  and  itching  of  the  skin  during  the  first  24  to  36  hours  of 
the  eruptive  stage. 


THE  INFECTIOUS  DISEASES  253 

The  eyes  should  be  bathed  frequently  with  a  warm  boric  acid 
solution  and  the  bright  light  excluded.  Dark  glasses  may  have 
to  be  worn  for  some  weeks  subsequently,  on  account  of  the 
sensibility  to  light. 

For  the  intense  itching  of  the  skin,  an  olive  oil  rub  will  usually 
lessen  the  irritation. 

In  uncomplicated  cases  the  child  is  usually  fully  convalescent 
within  a  week  from  the  first  appearance  of  the  rash. 

Complications. — The  complication  most  to  be  dreaded  in 
measles  is  bronchopneumonia.  It  is  particularly  liable  to  attack 
poorly-nourished  children.  In  institutions  for  children  measles 
must  therefore  be  regarded  as  a  serious  disease.  When  a  cough 
persists  for  a  long  time  following  measles,  tuberculosis  must 
always  be  kept  in  mind  and  the  patient  thoroughly  examined  by  a 
physician.  Another  complication  rather  common  in  measles  is 
otitis  media.  The  heart  should  be  examined  frequently,  for, 
although  affections  of  the  heart  are  not  so  common  in  measles 
as  in  some  of  the  other  diseases,  they  are  by  no  means  rare. 

Children  suffering  from  measles  should  be  kept  in  bed  until 
the  rash  has  disappeared,  and  they  should  not  be  allowed  to  go 
out  of  doors  in  winter  until  the  cough  has  ceased. 

During  the  entire  illness  an  abundance  of  fresh  air,  warmed 
to  a  temperature  of  65°  to  70°  F.,  should  be  furnished.  The  air 
should  be  kept  moist  by  a  steam  kettle.  It  will  be  found  that 
inhalations  of  steam,  to  which  some  tincture  of  benzoin  (3i-i 
pint  water)  has  been  added,  will  do  much  to  modify  the  laryngeal 
irritation  in  these  cases. 

Quarantine. — According  to  Holt,  the  average  infectious 
period  of  measles  is  three  weeks.  This  is  a  much  longer  period 
than  the  average  child  is  quarantined.  This,  together  with  the 
fact  that  most  cases  are  not  isolated  during  the  initial  stage  of  the 
disease,  probably  accounts  for  its  wide-spread  epidemic  character. 

Slight  desquamation  sometimes  occurs  after  measles.  This 
rarely,  if  ever,  involves  the  soles  of  the  feet  or  the  palms  of  the 
hands. 


254  CARE  OF  INFANTS  AND  CHILDREN 

German  Measles — Rubella 

Rubella  is  an  acute  contagious  disease  occurring  almost  always 
in  epidemics,  although  it  is  not  nearly  so  contagious  as  scarlet 
fever  or  measles.  The  incubation  period  varies  from  lo  to  21 
days.  The  prodromal  symptoms  are  usually  slight  and  of  short 
duration  and  consist  of  fever  and  general  malaise.  Occasionally 
the  disease  is  ushered  in  by  a  convulsion  and  high  fever.  The 
eruption,  which  is  somewhat  variable,  usually  resembles  measles. 
It  appears  first  on  the  face  and  spreads  rapidly  to  the  body  and 
extremities.  The  coryza,  laryngitis,  photophobia  and  Koplik's 
spots  of  measles,  however,  are  absent.  The  most  constant 
symptom  is  swelling  of  the  postcervical  glands,  and  particularly 
those  behind  the  ear  over  the  mastoid.  There  may  be  a  mild  sore 
throat.  By  the  time  the  rash  is  fully  out  the  temperature  has 
usually  disappeared.  The  rash  fades  rapidly  and  the  patient, 
after  a  day  or  two,  is  apparently  as  well  as  ever.  There  is  usually 
slight  desquamation  of  tiny  scales  scattered  over  the  entire  body. 
If  the  case  is  not  seen  until  the  scaling  has  begun  it  may  be 
mistaken  for  a  mild  case  of  scarlet  fever. 

The  treatment  is  purely  symptomatic.  The  food  should  be 
light  and  the  bowels  kept  open,  if  necessary,  with  a  simple  laxa- 
tive.    There  are  rarely  any  serious  complications. 

Varicella — Chicken-pox 

Chicken-pox  is  an  acute  contagious  disease  characterized  by 
an  eruption  on  the  skin  of  papules  and  later  vesicles  which  are 
typical  in  appearance,  and  by  mild  constitutional  symptoms.  The 
specific  poison  is  not  known,  but  it  is  conceded  to  be  very  con- 
tagious, rivalling  measles  in  this  respect.  The  contagious 
element  is  contained  in  the  vesicles,  and  probably  also  in  the 
breath. 

Incubation  Period. — The  incubation  period  is  from  14  to  16 
days.  The  appearance  of  the  eruption  may  be  preceded  by  a 
short  period  of  malaise  and  slight  fever.  In  many  cases  the 
eruption  is  the  first  evidence  of  the  disease.  The  number  and 
distribution  of  the  vesicles  is  extremely  variable.     There  may 


THE  INFECTIOUS  DISEASES  255 

not  be  over  a  dozen  or  so  on  the  entire  body,  or  the  eruption  may 
be  so  closely  crowded  as  to  be  conHuent. 

The  vesicles  occur  in  successive  crops  extending  over  a  period 
of  several  days,  the  first  ones  often  forming  crusts  before  new 
ones  appear.  The  vesicles  may  occur  also  on  the  scalp  and  on 
the  mucous  membrane  of  the  mouth  and  tongue.  In  one  case 
I  saw  a  pock  on  the  inside  of  the  eyelid. 

In  mild  cases  there  are  few  symptoms  of  any  moment,  but  in 
severe  confluent  cases  there  may  be  severe  poisoning  from  a  pus 
infection  of  the  skin. 

For  the  intense  itching  carbolized  vaseline  usually  gives 
marked  relief. 

Pitting. — Scratching  should  be  prohibited  because  of  the 
danger  of  infection  and  also  because  the  pitting  will  be  much 
exaggerated  if  the  scab  is  constantly  removed. 

The  child  should  be  isolated  until  the  crusts  have  fallen  off. 
The  urine  should  be  examined,  as  nephritis  is  an  occasional 
complication. 

Smallpox — Variola 

Smallpox  is  an  acute,  highly  infectious  disease.  It  occurs 
in  epidemics  where  the  public  is  not  protected  by  vaccination. 

It  is  contracted  usually  by  coming  in  close  proximity  with 
some  one  suffering  from  the  disease  although  it  may  readily  be 
carried  by  soiled  clothing,  utensils,  or  by  a  third  person. 

Before  vaccination  was  introduced  by  Jenner,  in  England, 
about  the  year  1774,  small-pox  was  epidemic  annually  during 
certain  seasons  of  the  year,  especially  during  the  cold  weather. 

No  age  is  exempt  and  there  are  many  authentic  cases  recorded 
in  which  the  foetus  suffered  from  smallpox  in  utero.  Such  cases 
have  been  known  to  recover  without  the  mother  miscarryirig,  and 
at  birth  the  baby  showed  the  pock-marks  typical  of  the  disease. 
One  attack  gives  immunity  for  life. 

Results  of  Vaccination. — Much  of  the  smallpox  seen  now 
is  mild  and  very  atypical  as  a  result  of  previous  vaccination. 

In  typical  cases  the  onset  is  sudden.     There  is  usually  a 


256  CARE  OF  INFANTS  AND  CHILDREN 

severe  chill  or  convulsion,  severe  headache,  and  often  an  intense 
pain  in  the  lumbar  region.  The  temperature  during  the  first  day 
may  reach  104°  F.,  or  higher.  There  is  frequently  great  restless- 
ness and  delirium.     The  tongue  is  coated  and  the  breath  foul. 

Eruption. — The  eruption  usually  appears  on  the  third  day, 
but  may  be  delayed  until  the  fourth  or  fifth.  It  appears  first  on 
the  face  and  wrists  and  then  spreads  over  the  entire  body,  with 
certain  characteristic  groupings.  The  eruption  appears  first  as 
a  papule,  which  gradually,  within  a  few  days,  becomes  shotty  to 
the  touch.  Within  24  hours  these  papules  are  changed  to  vesicles, 
and  are  gradually  transformed  into  pustules.  The  vesicles,  or 
pustules,  are  surrounded  by  an  intensely  red  area,  as  is  also  the 
vesicle  of  chicken-pox.  The  pustules  gradually  dry  and  form 
crusts.  In  severe  Cases,  where  the  pocks  are  crowded  closely 
together,  they  become  confluent,  so  that  later  the  crusts  may  be 
practically  continuous.  A  hemorrhagic  form  of  smallpox  is  also 
described,  which  is  particularly  fatal. 

Complications. — The  chief  complications  of  smallpox  are 
due  to  the  general  septic  condition  resufting  from  the  pus  infec- 
tion. There  is  no  organ  in  the  whole  body  which  may  not  be 
affected  by  the  disease. 

^The  average  course,  fortunately,  in  cases  which  have  been 
successfully  vaccinated,  is  rather  mild. 

Vaccination  After  Exposure. — When  a  child  has  been  ex- 
posed to  smallpox  it  should  be  vaccinated  at  once,  as  there  is 
usually  time  for  the  vaccine  to  "  take  "  before  onset  of  the  small- 
pox. 

The  general  treatment  is  symptomatic  and  will  vary  with  the 
individual  case. 

Mumps — Epidemic  Parotitis 

Mumps  is  an  acute  infectious  disease  characterized  by  slight 
prodromal  symptoms  and  swelling  of  one  or  both  parotid  glands, 
with  a  tendency  to  affect  the  testicles  in  males  and  the  ovaries  in 
females.     The  submaxillary  glands  may  at  times  be  involved. 


THE  INFECTIOUS  DISEASES  257 

One  or  both  parotids  may  be  affected.  The  disease  is  con- 
tagious, but  not  higlily  so,  it  being  conveyed  from  one  to  another 
by  the  breath  or  by  utensils,  such  as  towels,  dishes,  etc.  The 
incubation  period  is  from  14  to  21  days.  The  appearance  of  one 
suffering  from  mumps  is  typical.  The  gland  which  is  located  in- 
front  and  below  the  ear  is  swollen,  the  swelling  reaching  its 
height  about  the  third  day.  The  ear  seems  to  stand  out  from 
the  head.  The  skin  is  shiny  in  appearance  and  "  doughy  to  the 
feel."  The  gland  does  not  break  down,  as  in  most  other 
infections. 

After  a  few  days  the  swelling  gradually  subsides  and  the 
gland  returns  to  its  normal  size. 

During  the  acute  stages  there  is  usually  some  fever,  101° 
to  103°  F.  There  is  usually  considerable  pain  and  discomfort, 
especially  when  an  attempt  is  made  to  open  the  mouth.  One 
attack,  if  both  sides  are  involved,  usually  renders  the  patient 
immune  for  life.  If  only  one  side  is  involved,  a  subsequent 
attack  may  involve  the  other  gland. 

Orchitis. — "  Orchitis  is  met  with  not  infrequently,  especially 
in  boys  approaching  the  age  of  puberty,"  and,  according  to  one 
authority,  occurs  in  about  16  per  cent,  of  males  of  all  ages.  It 
may  occur  several  weeks  after  the  parotitis. 

The  testis  becomes  swollen  and  tender  and  there  are  usually 
marked  constitutional  symptoms. 

Involvement  of  the  Ovaries. — In  girls  the  vulva  and 
ovaries  may  be  affected.  In  severe  cases  the  inflammation  is 
followed  by  an  atrophy  and  destruction  of  the  function  of  the 
gland. 

Treatment. — The  patient  should  be  kept  in  bed  until  some 
days  after  the  inflammation  of  the  parotid  has  subsided.  The 
nourishment  will  usually  have  to  be  of  liquid  consistency  and 
may  be  taken  by  older  children  through  a  glass,  tube  or  straw. 
In  young  children  with  double  parotitis  it  may  be  necessary  to 
feed  them  through  a  tube  passed  through  the  nose. 

The  pain  in  the  gland  may  be  relieved  by  hot  fomentations. 

17 


258  CARE  OF  INFANTS  AND  CHILDREN 

Where  orchitis  or  ovaritis  occurs  the  patient  should  he  kept 
constantly  in  bed  and  ice  or  hot  applications  applied  to  the 
affected  gland.  These  measures  should  only  be  taken  under  the 
advice  of  a  physician. 

The  patient  is  probably  capable  of  infecting  others  for  several 
weeks  from  the  onset  of  the  disease. 

Pertussis — Whooping-cough 

Whooping-cough  is  a  specific  contagious  disease  characterized 
by  catarrhal  congestion  of  the  upper  respiratory  passages  and  a 
paroxysmal  cough  ending  in  a  long-drawn  inspiration  or 
"  whoop." 

Fatality  in  Young  Infants. — In  young  infants  pertussis 
is  a  very  fatal  disease,  and  even  in  older  children  it  is  not  a  con- 
dition to  be  regarded  too  lightly.  It  occurs  in  epidemics  and  is 
transmitted  from  one  person  to  the  other  by  means  of  the  breath, 
or  more  probably  by  'the  saliva  which  is  thrown  from  the  mouth 
and  throat  during  a  paroxysm  of  coughing.  Czerny,  in  a  recent 
communication,  says  that  in  his  experience  whooping-cough  is 
not  as  infectious  as  is  generally  supposed.  When  a  child  with 
whooping-cough  was  accidentally  admitted  to  a  ward  and  kept  in 
bed  at  a  distance  of  1I/2  metres  (about  five  feet)  from  the  adjoin- 
ing beds,  the  other  children  did  not  contract  the  disease.  The 
incubation  period  is  probably  about  14  days. 

The  onset  is  gradual,  and  for  the  first  week  or  two  there  may 
be  nothing  more  than  a  cough,  which,  however,  comes  on  peri- 
odically. The  child  wakes  out  of  a  sound  sleep  and  has  a  fit  of 
coughing  and  then  goes  to  sleep  again.  The  secretion  which 
comes  from  the  throat  during  this  time  is  of  a  clear  viscid  char- 
acter. Gradually  the  paroxysms  become  more  severe,  and  in 
typical  cases  the  face  becomes  intensely  red  and  sometimes 
cyanosed,  the  eyes  prominent,  and  the  conjunctiva  injected,  and 
the  pupils  dilated.  At  the  end  of  the  successive  expiratory  coughs 
comes  the  "  whoop  "  with  inspiration.  This  may  be  repeated  sev- 
eral times,  until  the  child  is  completely  exhausted.     The  child 


THE  INFECTIOUS  DISEASES  259 

knows  when  an  attack  is  coming  and  runs  to  the  mother  or  nurse 
for  support.  Convulsions  are  a  frequent  and  extremely  dan- 
gerous complication  in  young  infants. 

Vomiting. — During  the  attack,  if  the  stomach  contains  food 
it  is  liable  to  be  expelled  by  vomiting.  In  many  cases  the  vomit- 
ing is  so  persistent  that  the  child  soon  begins  to  show  the  result 
of  starvation. 

In  these  cases  concentrated  liquid  food  should  be  given  and  in 
small  quantities,  rather  often,  with  the  idea  of  having  the  stom- 
ach empty  itself  quickly.  Where  the  vomiting  is  persistent  an 
adhesive  strip,  two  to  three  inches  wide,  drawn  tightly  over  the 
lower  part  of  the  thorax  at  the  level  of  the  diaphragm,  will  do 
much  to  prevent  the  regurgitation  of  food. 

Spasmodic  Stage. — The  spasmodic  stage  lasts  for  a  variable 
period  of  from  three  weeks  to  three  or  four  months.  If  the 
disease  occurs  in  winter  it  is  liable  to  be  especially  long  drawn  out, 
and  with  every  little  "  cold  "  the  whooping  begins  again.  The 
severest  period  usually  lasts  about  three  weeks.  In  mild  cases 
there  may  be  no  real  whooping,  and  there  may  be  doubt  as  to 
the  diagnosis.  The  paroxysmal  character  of  the  cough,  par- 
ticularly the  waking  out  of  a  sound  sleep  with  a  paroxysm,  is 
always  suspicious. 

Treatment. — The  treatment  consists  largely  in  keeping 
up  the  patient's  vitality.  There  are  no  specifics.  In  good 
weather,  even  in  winter,  the  children,  if  rugged,  should  be  kept 
out  of  doors  as  much  as  possible.  In  New  York  City  children 
with  whooping-cough  who  play  out  of  doors  are  required  to  wear 
a  band  across  the  arm  or  chest  with  the  word  "  whooping- 
cough  "  printed  thereon.  For  young  infants  the  air  should  be 
.kept  fresh,  moist,  and  of  a  uniform  temperature.  Most  of  the 
cures  which  are  recommended  by  the  laity  are  really  harmful 
and  should  not  be  used. 

The  chief  complications  to  be  dreaded  are  pneumonia  and 
acute  dilatation  of  the  heart. 


26o  CARE  OP  INFANTS  AND  CHILDREN 

When  the  paroxysms  are  particularly  severe  there  may  be 
temporary  paralysis  of  some  of  the  muscles  resulting  from 
minute  hemorrhages  in  the  brain  or  from  the  accumulation  of 
fluid.  Bleeding  from  the  nose  is  common,  and  there  may  be 
hemorrhages  into  the  conjunctivae  or  into  the  tissues  in  and 
around  the  orbits. 

Diphtheria 

Diphtheria  is  an  acute  infectious  disease  due  to  the  Klebs- 
Loffler  bacillus  (diphtheria  bacillus).  The  disease  usually  be- 
gins in  the  upper  air  passages,  on  the  tonsils,  in  the  nose  or  in 
the  larynx,  and  is  characterized  by  the  formation  of  a  false 
membrane  which  is  more  or  less  typical  in  appearance.  The 
diagnosis  is  made  definitely  by  a  culture  and  a  microscopic  ex- 
amination. There  is  no  other  way  of  positively  differentiating 
diphtheria  from  some  of  the  forms  of  inflammation  in  which  a 
membrane  is  present. 

Diphtheritic  membrane  occurring  in  the  eyes  and  vulva  is 
rare  and  is  usually  due  to  secondary  infection. 

Diphtheria  Toxin.s. — The  growth  of  the  diphtheria  bacillus 
in  the  throat  or  nose  produces  toxins  which  are  absorbed  into 
the  general  circulation,  producing  the  serious  symptoms  which 
so  often  develop  in  diphtheria. 

Means  of  Dissemination. — The  disease  is  readily  com- 
municated from  one  to  another  by  reasonably  close  contact,  and 
is  often  spread  by  carriers,  as  well  as  by  milk  and  other  indirect 
.means.  In  a  recent  epidemic  in  St.  Paul  over  200  cases  of 
diphtheria  developed  from  one  dairy.  Upon  examination  by 
the  department  of  health  two  men  who  were  employed  in  milk- 
ing the  cows  were  found  to  be  suffering  from  a  mild  attack  of 
diphtheria. 

Incubation  Period. — The  incubation  period  is  variable,  but 
is  usually  short,  varying  from  one  to  four  days. 

The  onset  is  usually  sudden,  beginning  often  with  vomiting 
and  sore  throat.  There  is  some  elevation  of  temperature  and 
the  pulse  is  usually  much  increased  in  frequency. 


THE  INFECTIOUS  DISEASES  261 

Appearance  of  Throat. — If  the  throat  is  examined  during 
the  first  few  hours  there  may  usually  be  seen  a  patch  of  mem- 
brane on  one  or  both  tonsils.  This  is  usually  of  a  grayish- white 
color,  but  may  be  white.  It  rapidly  spreads  and  in  a  few  hours 
may  cover  the  tonsils,  and  within  24  or  36  hours  the  pillars  of 
the  soft  palate  and  uvula.  There  is  usually  some  swelling  of 
the  cervical  lymph-glands,  and  in  severe  cases  there  is  consider- 
able oedema.  Swallowing  is  usually  somewhat  painful.  If  the 
disease  begins  in  the  nose  it  may  be  overlooked,  and  some  time 
may  elapse  and  severe  general  symptom.s  develop  before  a  diag- 
nosis is  made. 

Nasal  Diphtheria. — There  is  often  an  excoriation  of  the 
skin  about  the  nostrils,  sometimes  extending  well  down  on 
the  lip.  Whenever  such  an  excoriation  is  seen,  a  culture  should 
be  made  and  the  child  isolated  until  a  report  is  received  from 
the  health  department.  Some  years  ago  such  a  case  was  ad- 
mitted to  one  of  my  wards  and  was  not  recognized  until  many 
other  children  had  developed  diphtheria.  A  one-sided  nasal 
discharge  of  a  serous  character  will  usually  be  found  to  be 
diphtheria. 

Laryngeal  diphtheria  frequently  extends  from  the  pharynx, 
but  may  develop  primarily. 

Membranous  croup  was  formerly  thought  to  be  an  independ- 
ent disease,  but  is  now  known  to  be  laryngeal  diphtheria. 

Membranous  croup  and  spasmodic  croup  are  still  often  con- 
fused in  the  public  mind.  When  a  spasmodic  croup  persists  for 
more  than  a  few  hours  after  the  ordinary  remedies,  such  as 
ipecac  and  the  steam  tent,  have  been  tried,  a  physician  should 
always  be  sent  for  and  a  critical  examination  made  and  a  culture 
from  the  larynx  taken.  The  patient  thereafter  should  be  care- 
fully watched,  as  intubation  may  be  necessary. 

The  general  symptoms  of  diphtheria  are  those  of  a  general 
toxaemia,  the  most  serious  effects  of  which  are  evident  in  the 
heart  and  nervous  system. 

Heart  Involvement. — The  toxins  act  both  on  the  heart 


262  CARE  OF  INFANTS  AND  CHILDREN 

muscle,  producing  a  degeneration,  and  ujx)n  the  nerves  con- 
trolling the  heart  and  blood-pressure,  as  well  as  upon  the  motor 
nerves. 

The  pulse  is  usually  rapid  at  first,  but  in  favorable  cases 
gradually  returns  to  normal.  In  severe  cases  the  pulse  is  rapid 
and  of  low  tension,  or  later  slow  and  irregular,  frequently  missing 
every  second  or  third  beat. 

The  heart  is  frequently  dilated,  the  apex  beat  extending 
often  considerably  to  the  left  of  the  nipple  line.  These  irregu- 
larities of  the  heart  may  come  on  several  weeks  after  the  patient 
is  apparently  convalescent. 

Paralysis  of  certain  muscles  or  groups  of  muscles  is  common 
following  diphtheria.  Strabismus  is  common,  due  to  paralysis 
of  the  recti  muscles.  Paralysis  of  the  throat  muscles  is  com- 
mon, manifested  usually  by  an  inability  to  swallow  liquids,  the 
food  regurgitating  through  the  nose.  Great  care  and  careful 
nursing  are  required  in  these  cases  to  see  that  the  patient  gets 
sufficient  food  to  maintain  the  general  nutrition.  It  may  be 
necessary  to  feed  him  for  a  time  by  means  of  a  tube,  introduced 
into  the  stomach  by  way  of  the  nose. 

Par.\lysis. — This  paralysis  is  due  to  the  toxin  of  the  diph- 
theria and  not  to  the  antitoxin,  as  is  frequently  believed  by  the 
laity.  In  the  pre-antitoxin  days  postdiphtheritic  paralysis  zvas 
much  more  common  than  it  is  to-day. 

Treatment. — Antitoxin  is  a  specific  for  diphtheria,  and 
when  given  early  enough  and  in  sufficient  doses  the  death  rate 
is  very  small.  Before  1896,  when  antitoxin  began  to  come  into 
general  use,  the  mortality  from  diphtheria  varied  from  20  to  35 
per  cent.  Since  antitoxin  has  been  used  as  a  routine,  the  death 
rate  in  the  St.  Paul  City  and  County  Hospital  has  not  been  over 
6.5  per  cent,  and  that  in  a  hospital  where  usually  the  worst 
cases  are  sent  for  treatment. 

If  every  case  in  which  there  is  a  membrane  in  the  throat 
were  regarded  with  suspicion  and  a  culture  made  at  once,  the 
death  rate  from  diphtheria  would  be  still  much  lower  than  it 
is  to-day. 


THE  INFECTIOUS  DISEASES  263 

Antitoxin. — The  antitoxin  is  usually  given  subcutaneously 
between  the  shoulders,  or  in  the  loose  subcutaneous  tissue  of 
the  abdomen.  It  may  be  given  intramuscularly  or  intravenously. 
The  skin  should  be  well  cleansed  with  soap  and  water  and  then 
with  alcohol,  or  some  tincture  of  iodine  may  be  painted  over  the 
area  where  the  injection  is  to  be  given.  The  area  where  the 
injection  is  made  should  not  be  rubbed  or  massaged  to  promote 
the  absorption  of  the  serum,  as  an  abscess  may  result.  Several 
injections  may  be  given  on  successive  days,  as  determined  by 
the  symptoms. 

When  sufficient  antitoxin  is  given  at  the  initial  dose,  and 
early  enough,  there  is  usually  an  amelioration  of  the  symptoms 
after  24  to  36  hours.  The  temperature  falls,  the  swelling  of 
the  glands  of  the  neck  gradually  subsides,  and  the  membrane  in 
the  throat  begins  to  loosen  around  the  edges.  In  favorable  cases 
after  two  or  three  days  the  membrane  has  disappeared,  and  the 
patient  is  convalescent.  It  is  often  at  this  time  that  the  heart 
complications  begin  to  appear. 

All  cases  of  diphtheria  should  be  kept  in  the  recumbent 
position  for  at  least  three  weeks,  and  this  rule  should  be  de- 
parted from  only  by  the  consent  of  the  physician.  The  sudden 
deaths  from  heart  paralysis  usually  result  from  sitting  up  sud- 
denly and  often  when  the  patient  feels  perfectly  well.  When 
the  pulse,  following  a  severe  diphtheria,  drops  down  as  low  as 
35  to  40  beats  per  minute,  and  especially  if  irregular,  it  usually 
means  a  serious  heart  affection.  The  child  should  not  be  allowed 
to  move  from  the  horizontal  position  under  any  consideration. 
The  time  during  which  a  patient  must  remain  in  the  recumbent 
position  will  depend  entirely  upon  the  heart  findings,  but  it 
should  be  much  longer  than  is  generally  deemed  necessary.  It 
will  usually  be  necessary  to  put  young  children  in  a  restraining 
sheet  to  keep  them  from  sitting  up. 

General  Care  and  Feeding. — The  general  care  and  feeding 
of  these  cases  is  of  the  greatest  importance.  The  food  should 
be  simple,  but  nutritious,  and  the  bowels  kept  open  with  simple 


264 


CARE  OF  INFANTS  AND  CHILDREN 


enemas.  Some  general  massage  will  be  necessary  to  keep  the 
skin  from  showing  the  effects  of  pressure  in  the  cases  which 
must  remain  long  in  the  recumbent  position.  An  air  cushion 
or  two  will  often  be  indispensable. 


LARYNGEAL    DIPHTHERL\ 

When  there  is  a  marked  obstruction  from  membrane  in  the 
larynx,  so  that  the  suprasternal  notch  is  markedly  retracted  with 
each  inspiration,  intubation  or  tracheotomy  should  be  performed. 
Intubation  with  an  O'Dwyer  tube   (Fig.   117)   is  the  simplest 


Fig.  in. — Instruments  for  intubation  and  tracheotomy.  1,  O'Dwyer  tubes;  2,  mouth 
gag;  3,  silk;  4,  obturator  for  introducing  tube;  5,  retractor  for  removing  tube;  6,  tracheot- 
omy tubes. 

operation,  and  the  physician,  unless  there  is  some  contraindica- 
tion, will  usually  prefer  it.  Both  the  intubation  and  tracheotomy 
instruments  should,  however,  be  ready  for  the  physician  when 
he  arrives,  as  usually  no  time  is  to  be  lost. 

The  proper  tubes  according  to  the  age  of  the  child  should 
be  selected  and  threaded  with  silk,  and  all  of  the  instruments 
sterilized. 

Intubation. — The  child  should  be  rolled  in  a  sheet,  with 
the  hands  by  the  sides  and  the  sheet  pinned  firmly  with  safety- 
pins.  A  small  roll  should  be  provided  for  the  back  of  the  neck. 
The  tube  is  introduced  while  the  child  is  in  the  horizontal  posi- 


THE  INFECTIOUS  DISEASES 


265 


tion  (Fig.  118).  The  string  may  be  left  in  and  plastered  to  the 
side  of  the  cheek  by  means  of  an  adhesiye  strip.  In  this  case 
the  hands  should  be  restrained,  or  the  child  will  pull  out  the 
tube.  After  24  hours  it  is  often  removed.  If  any  obstruction 
occurs  in  the  tube  it  may  be  removed  by  making  traction  on  the 
string. 

Tracheotomy. — When  tracheotomy  is  done  a  tube  is  in- 
troduced into  the  opening  and  held  in  place  by  braid  tied  around 
the  neck.  One  tube  which  fits  within  the  other  is  removed  at 
intervals,  and  the  secretion  removed,  and  then  reintroduced. 


Fig.   118. — Position  of  child  for  intubation.     (St.  Paul  City  and  County  Hospital.) 

In  both  cases  the  children  will  be  kept  in  a  steam  tent  for 
several  days  (Fig.  119).  In  the  use  of  the  steam  tent  care  must 
be  taken  to  insure  the  patient  a  proper  amount  of  fresh  air.  An 
aperture  above  and  below  sufficient  for  proper  circulation  of 
air  should  always  be  maintained. 

Feeding. — The  feeding  of  intubation  cases  is  at  first  difficult. 
The  head  should  be  lowered  and  only  liquid  diet  given,  which 
is  done  slowly,  with  a  spoon.  These  cases  soon  learn  how  to 
use  the  base  of  the  tongue  to  protect  the  opening  in  the  tube, 
so  that  after  the  first  day  there  is  little  difficulty. 


266 


CARE  OF  INFANTS  AND  CHILDREN 


Removal  of  Tube. — The  tube  is  left  in  usually  for  a  few 
days,  and  then  removed.  It  is  not  unusual  that  a  sudden  attack 
of  dyspnoea  necessitates  its  immediate  reintroduction,  so  that 
before  a  tube  is  removed  all  necessary  instruments  should  be  at 
hand.  It  must  be  remembered  that  intubation  and  tracheotomy 
are  only  measures  to  relieve  the  obstruction,  and  that  the  cure 
for  the  condition  is  antitoxin  in  early  and  sufficient  doses. 

Quarantine  is  usually  maintained  until  two  successive  negative 
cultures  from  the  throat  and  one  from  the  nose  (both  sides)  are 


Fig.  119.— Steam  tent. 


obtained.  Many  means  have  been  recommended  for  hastening 
the  disappearance  of  the  bacilli  from  the  throat,  but  none  of 
them  have  been  very  successful.  The  mildest  ones  are  often 
the  ones  in  which  the  bacilli  persist  the  longest. 


Typhoid  Fever 

Typhoid  fever  is  an  acute  infectious  disease  due  to  the 
typhoid  bacillus.  It  is  not  common  in  infants  under  two  years, 
but  undoubtedly  occurs  more  often  than  is  generally  supposed. 
Typhoid  may  infect  a  child  in  utero,  the  bacilli  passing  directly 
from  the  mother's  blood  to  that  of  the  foetus  (Morse). 


THE  INFECTIOUS  DISEASES  267 

During  childhood  the  disease  is  common  and  its  course  does 
not  differ  essentially  from  that  occurring  in  adults. 

Lesions  in  the  Bowel. — The  lesions  are  primarily  in  the 
Peyer's  glands,  producing  ulceration  and  occasionally  intestinal 
hemorrhage  and  perforation. 

Sources  of  Infection. — Milk,  of  course,  is  a  common  source 
of  infection,  well-water  which  has  been  contaminated  by  drain- 
ings  from  out-houses  being  the  original  source  of  infection  in 
the  majority  of  cases. 

Infants  with  typhoid  fever  are  frequently  sources  of  infection 
to  other  members  of  the  family.  In  changing  the  diaper  the 
mother's  hands  usually  become  soiled,  and,  unless  she  is  scru- 
pulously clean,  she  may  readily  infect  herself  and  others  through 
the  food.  The  fever  is  continuous,  with  morning  and  evening 
remissions.  There  is  usually  some  diarrhoea,  often  of  the  "  pea- 
soup  "  variety.  The  spleen  is  enlarged  and  can  be  palpated  in 
more  than  half  the  cases,  and  there  are  usually  successive  crops 
of  rose-spots  scattered  over  the  abdomen,  and  sometimes  over 
the  entire  body.  After  the  end  of  the  first,  or  beginning  of  the 
second,  week,  the  Widal  reaction  v^ill  usually  be  positive, 
although  in  children  it  may  be  negative  until  convalescence  is 
established,  and  then  become  positive. 

The  nursing  of  typhoid  is  the  essential  thing  in  the  way  of 
treatment. 

Diet.- — The  diet  is  of  the  greatest  importance.  Uncooked 
whole  milk  is  a  poor  diet  for  typhoid,  either  in  children  or 
adults.  The  milk  should  be  skimmed  and  boiled  and  well  diluted 
with  cereal  gruels  and  sugar,  to  increase  the  caloric  value,  as 
well  as  to  modify  the  intestinal  flora. 

Buttermilk. — Buttermilk,  to  which  flour  and  sugar  have 
been  added,  is  an  ideal  diet  for  typhoid  in  children ;  the  tongue 
remains  moist  and  the  abdomen  is  little,  if  at  all,  distended, 
and  the  stools  lack  the  evidence  of  putrefactive  changes  which 
is  present  when  the  diet  consists  of  whole  milk  (unsoured).  It 
is  quite  possible  by  giving  large  amounts  of  cereal  gruels  with 


268  CARE  OF  INFANTS  AND  CHIUDREN 

sugar  and  a  proper  amount  of  proteid  to  have  children  run  a 
course  of  several  weeks  and  lose  little,  if  any,  in  weight. 

Baths, — Children  should  rarely  have  cold  haths.  Cool 
sponging  will  usually  be  all  that  is  necessary.  The  indications 
for  cold  sponging  are  restlessness,  high  fever,  and  delirium. 

Care  of  Mouth  and  Teeth. — The  mouth  should  receive 
special  care  in  typhoid.  The  teeth  and  tongue  should  be  kept 
free  from  hardened  secretions,  as  serious  secondary  infections 
may  result.  For  this  an  alkaline  solution  such  as  Seiler's  should 
be  used. 

Bed-sores. — Great  care  must  be  taken  in  these  cases  that 
bed-sores  do  not  develop.  When  there  is  any  evidence  of  pres- 
sure, as  shown  by  redness  of  the  skin,  an  air  cushion  should  be 
provided  at  once.  After  the  skin  is  once  broken  it  is  difficult 
to  heal  and  secondary  mixed  infections  are  particularly  liable 
to  occur  in  these  cases. 

Bowels. — When  the  bowels  are  constipated  physic  should 
not  be  given,  but  the  lower  bowel  should  be  emptied  daily  with 
a  simple  enema  of  normal  salt  solution. 

Vaccination. — During  the  past  few  years  vaccination  has 
been  successfully  practised  as  a  preventive  measure  against  ty- 
phoid fever.  The  vaccine  consists  of  a  solution  of  the  dead 
typhoid  bacilli  which  are  introduced  into  the  skin  by  means 
of  a  hypodermic  syringe.  Since  routine  vaccination  has 
been  practised  in  the  United  States  Army,  very  few  cases  of 
typhoid  bacilli  which  are  introduced  under  the  skin  by  means 
tropics,  where  formerly  large  numbers  were  infected.  If  chil- 
dren are  to  be  subjected  to  conditions  where  the  milk  and  water 
supply  are  uncertain,  as  might  occur  in  travelling  or  during  an 
epidemic,  they  should  be  vaccinated  against  typhoid,  unless  there 
is  some  definite  contraindication. 

Tuberculosis 
Tuberculosis  is  an  infectious  disease  produced  by  the  tubercle 
bacillus.  There  are  at  least  three  varieties  of  the  tubercle  bacillus : 


THE  INFECTIOUS  DISEASES 


269 


human,  bovine,  and  avian,  the  last   form  producing  so  Httle 
trouble  in  human  beings  that  it  will  not  be  considered  here. 
It  is  now  practically  proven  that  bovine  tuberculosis  may 


Fig.   120. — Tubcrculou?  disease  of  the  vertebrae.     (Pott's  disease). 


infect  human  beings,  although  for  many  years  Koch  taught  the 
contrary. 

Tuberculosis  may  be  local  or  general.  Almost  any  organ  or 
portion  of  the  body  may  be  the  seat  of  a  tuberculous  infection 
(Fig.  120). 

Means  of  Infection. — Tubercle  bacilli  mav  be  inhaled  with 


270 


CARE  OF  INFANTS  AND  CHILDREN 


the  air  and  directly  infect  the  upper  air  passages  or  the  lungs. 
The  bacilli  may  be  taken  up  by  the  tonsils  or  other  lymph-glands 
in  the  throat  and  be  carried  to  the  lymphatics  in  the  neck,  or 
the  bacilli  may  find  entrance  to  the  blood  stream  and  be  dis- 
seminated throughout  the  body,  producing  general  miliary 
tuberculosis. 

Cows  AND  Milk. — Cows  are  particularly  liable  to  tubercu- 
losis. It  is  estimated  in,  England  that  about  10  per  cent,  of  the 
milk  contains  tubercle  bacilli,  and  the  percentage  is  probably  not 
less  in  this  country.  Since  milk  is  frequently  given  uncooked 
to  children,  it  is  probable  that  a  considerable  number  are  infected 
in  this  way. 

Inheritance. — It  was  formerly  thought  that  children  fre- 
quently inherited  tuberculosis.  This  is  extremely  rare,  if  it  ever 
occurs.  Children  do  inherit  a  weakened  constitution  and  a  poor 
physique,  which  often  makes  them  easy  victims,  and  when  in- 
fected they  have  little  resistance.  The  fact  that  so  often  several 
members  of  a  family  die  one  after  another  with  tuberculosis  has 
served  more  than  anything  else  to  show  the  contagious  character 
of  the  disease. 

Personal  Habits  of  Tuberculosis  Patients. — Persons 
suffering  from  pulmonary  tuberculosis,  unless  closely  watched, 
are  prone  to  be  very  careless  about  destroying  the  sputum.  In 
coughing  there  is  a  constant  spray  of  infected  sputum  dissemi- 
nated about  the  room.  The  result  is  that  infection  of  other 
members  of  the  family  is  common. 

Meningitis. — Tuberculous  meningitis  is  common  in  chil- 
dren, as  is  also  tuberculous  infection  of  the  bones  and  joints, 
and  in  many  cases  it  is  difficult  or  impossible  to  trace  the  source 
of  the  infection. 

In  the  wasting  diseases  of  infancy  tuberculous  infections  of 
the  mediastinal  or  mesenteric  glands  are  more  common  than  is 
fT^enerally  suspected.  Enlargement  of  the  mediastinal  glands 
often  produces  a  cough  resembling  whooping-cough;  an  X-ray 
will  often  show  the  shadow  of  the  enlarged  glands. 


THE  INFECTIOUS  DISEASES  271 

Peritonitis. — Tuberculous  peritonitis  is  rather  common  in 
children  after  the  second  or  third  year.  There  may  be  a  large 
accumulation  of  fluid  in  the  peritoneal  cavity,  or  there  may  be 
no  fluid  but  the  omentum  becomes  involved,  forming  masses 
which  can  be  felt  through  the  abdominal  wall. 

Nursing  in  Tuberculosis. — A  tuberculous  mother  should 
not  nurse  her  baby ;  neither  should  she  have  the  care  of  it  if  she 
has  active  tuberculosis,  with  tubercle  bacilli  in  the  sputum. 

Children  should  never  be  taken  where  there  is  a  patient  with 
pulmonary  tuberculosis.  After  a  patient  with  pulmonary  tuber- 
culosis has  been  removed  from  a  house  the  entire  house  should 
be  renovated  and  repapered  or  painted,  before  it  is  occupied 
again. 

Treatment. — The  treatment  for  tuberculosis  in  children  is 
practically  the  same  as  for  adults.  Fresh  air  and  a  diet  as  high 
in  fat  as  can  be  assimilated.  Sleeping  out  of  doors  in  screened 
tents  or  houses  should  be  encouraged.  Even  the  school  should 
be  out  of  doors  ( Figs.  2.2  and  66) . 

Diet. — Cod-liver  oil  will  often  be  tolerated  by  young  chil- 
dren when  the  cream  of  cow's  milk  will  not  be.  One  must  be 
careful  not  to  crowd  the  diet  sufficiently  to  upset  the  digestion, 
otherwise  more  harm  than  good  will  result. 

Involvement  of  the  Joints. — Children  with  beginning  tu- 
berculosis of  the  hip-joint  are  usually  restless  at  night,  cry  out 
in  their  sleep,  complain  of  pain  about  the  knee,  and  limp  when 
walking.  When  lying  down  they  usually  have  the  leg  flexed. 
There  is  liable  to  be  a  daily  rise  of  temperature.  The  nurse 
should  recognize  these  symptoms  and  have  the  child  examined 
by  a  physician  early,  before  any  serious  changes  have  taken 
place  in  or  about  the  joint. 

Syphilis 
Syphilis  is  a  contagious  disease  produced  by  an  organism 
which  belongs  to  a  higher  class  than  the  bacteria — the  Spirocliccte 
pallida. 


272 


CARE  OF  INFANTS, AND  CHILDREN 


The  disease  may  be  inherited  or  acquired.  It  is  readily  ac- 
quired tlirough  an  open  wound  in  the  skin  or  through  the  nuicous 
membranes,  by  contact  with  syphihtic  secretion.  The  local  lesion 
takes  alx)Ut  a  month  to  develop  and  forms  what  is  generally 
known  as  a  chancre.  After  several  weeks  a  general  infection 
occurs,  as  evidenced  by  the  appearance  of  a  characteristic  rash. 

Children  born  of  syphilitic  parents  are  liable  to  inherit  the 
disease. 

Many  syphilitic  mothers  miscarry  repeatedly.  A  premature 
syphilitic  infant  rarely  lives  any  length  of  time. 


Fig.   121. — Syphilitic  eruption  on  the  soles  of  the  feet  of  new-born  infants. 


Infants  born  with  syphilis  at  full  term,  if  the  disease  is  not 
too  severe,  may,  if  they  can  nurse  the  mother  and  have  anti- 
syphilitic  treatment,  recover  from  the  disease  and  develop 
normally. 

Snuffles. — When  an  infant  develops  "  snuffles  "  within  the 
first  few  weeks  and  continues  to  have  a  discharge  from  the 
nose,  and  if  in  addition  there  is  a  rash  on  the  skin,  especially  on 
the  soles  of  the  feet  and  palms  of  the  hands,  or  sores  about  the 
lips  and  anus,  syphilis  should  always  be  suspected  and  the 
physician's  attention  be  called  to  the  condition  (Fig.  121). 

Dactylitis. — Many  of  these  cases  have  spindle-shaped  en- 


THE  INFECTIOUS  DISEASES  273 

largements  of  the  shafts  of  the  bones  of  some  of  the  fingers  or 
toes  (Fig.  122).  This  is  known  as  syphilitic  dactyhtis.  It  is 
significant,  but  not  pathognomonic,  of  syphilis,  as  it  may  also 
occur  in  tuberculosis. 

The  Teeth. — The  teeth  are  often  badly  formed  in  syphilitic 
children,  but  if  the  child  has  come  under  treatment  they  may 
be  normal.     Syphilis  which  has  gone  untreated  may  later  cause 


Fig.  122. — Syphilitic  dactylitis. 

serious  brain  lesions  or  extensive  ulcers  in  almost  any  portion 
of  the  body  (Fig.  31). 

Treatment. — The  treatment  for  syphilis  consists  of  mercury 
in  some  form  which  may  be  given  hypodermically,  by  mouth, 
or  by  inunction.  In  later  stages  it  is  frequently  combined  with 
iodide  of  potassium.  During  the  past  few  years  salvarsan  or 
neosalvarsan,  which  is  usually  injected  into  the  veins,  has  come 
into  quite  general  use.  It  is,  however,  usually  supplemented  by 
mercury  in  some  form. 

The  treatment  for  syphilis  should  extend  over  a  period  of 
three  years,  and  no  person  who  has  been  infected  should  marry 
18 


274  CARE  OF  INFANTS  AND  CHILDREN 

UTitil  two  years  after  the  last  symptoms  have  disappeared.  Dur- 
ing this  time  repeated  negative  Wassermanns  should  be  obtained. 

During  the  acute  stage,  when  there  are  open  sores  or  ulcers 
on  the  mucous  membranes,  the  disease  is  highly  contagious.  A 
syphilitic  baby  should  never  be  allowed  to  nurse  a  wet  nurse,  as 
she  will  almost  surely  contract  the  disease.  Syphilitic  infants 
should  be  kept  on  the  breast,  as  their  chances  for  recovery  are 
comparatively  small  if  fed  on  artificial  food. 

If  the  mother  cannot  nurse  the  baby,  breast  milk  should  be 
obtained  and  fed  through  a  nipple. 

If  any  suspicious  signs  of  syphilis  exist  in  either  parent,  the 
child  should  be  carefully  watched  for  many  years,  as  late  mani- 
festations are  not  uncommon. 

In  later  childhood  lesions  of  the  eyes  and  ears  due  to  inherited 
syphilis  are  frequent. 

Erysipelas 

"  Erysipelas  is  an  acute  infectious  disease  due  to  the  Strep- 
tococcus pyogenes."  The  inflammation  is  usually  limited  to  the 
lymphatic  spaces  in  the  skin.  The  infected  area  is  intensely  red, 
with  a  well-defined,  somewhat  raised  border  separating  it  from 
the  healthy  skin.  There  may  be  small  hemorrhages  into  the 
affected  skin,  or  there  may  be  small  vesicles  filled  with  serum 
raised  above  the  surface.  The  infection  usually  begins  at  some 
point  and  spreads  rapidly. 

In  new-born  infants  the  umbilicus  is  a  common  seat  of  in- 
fection, which  spreads  rapidly  over  the  abdomen  and  may  involve 
niuch  of  the  skin  of  the  trunk  and  limbs.  I  have  seen  several 
cases  in  which  the  infection  began  around  the  anus  and  one  in 
which  it  began  on  the  penis  after  circumcision.  These  cases  are 
not  so  fatal  as  those  which  have  their  origin  in  the  umbilicus. 
Umbilical  infections  may  result  in  abscess  in  the  liver  or  in  a 
general  peritonitis. 

The  most  common  seat  of  erysipelas  in  older  children  is  the 
face.     The  infection  usually  begins  about  the  nose  or  mouth 


THE  INFECTIOUS  DISEASES  275 

and  rapidly  spreads  over  the  entire  face,  and  often  the  neck, 
including  the  ears.  It  may,  however,  not  invade  the  scalp,  but 
may  limit  itself  to  the  hair  line. 

The  course  of  erysipelas  in  children  is  usually  severe,  the 
temperature  is  high,  and  there  are  evidences  of  great  prostration. 
Involvement  of  the  kidneys  is  common.  All  cases  of  erysipelas 
should  be  isolated,  and  under  no  circumstances  should  a  par- 
turient or  pregnant  woman  come  in  direct  or  indirect  contact 
with  the  disease.  Xo  nurse  should  go  from  the  care  of  such  a 
patient  to  a  case  of  confinement. 

The  treatment  consists  in  application  of  local  antiseptics, 
with  the  idea  of  limiting  the  infection.  "  When  the  disease 
begins  on  one  of  the  limbs  it  may  sometimes  be  headed  off  by 
injecting  some  antiseptic  into  the  skin  in  front  of  the  infection." 

The  attendant  should  exercise  every  care  to  prevent  infec- 
tion of  herself  through  small  cuts  or  hangnails. 


CHAPTER  XXXI 
HABITS 

There  are  certain  habits  which  infants  and  children  acquire 
which,  if  they  become  fixed,  are  capable  of  serious  injury  to  the 
individual.  The  sucking  of  the  fingers  when  hungry  is  with  chil- 
dren a  perfectly  natural  one,  but  ordinarily  it  is  not  persisted  in 
and  is  discontinued  spontaneously. 

Sucking 

Thumb  or  finger  sucking  is  a  rather  common  habit,  and  if 
persisted  in  may  result  in  deforming  both  the  thumb,  fingers  and 
the  alveolar  process,  producing  irregularities  of  the  teeth. 

Some  children  will  suck  the  skin  of  their  arm  or  a  part  of 
the  bed-clothes,  or  it  may  be  a  pacifier.  Pains  should  be  taken 
to  break  children  from  such  habits  before  they  become  fixed. 
Thumb-sucking  may  readily  be  prevented  by  applying  splints 
so  that  the  child  cannot  bend  its  arms  at  the  elbows. 

AIasturbation 

Masturbation  is  rather  common  to  both  sexes,  even  in  in- 
fancy. It  consists  in  irritating  the  genital  organs  with  the  hands, 
in  rubbing  the  thighs  together,  or  by  rubbing  against  some  object, 
such  as  a  chair  or  a  hobbyhorse. 

The  condition  may  first  have  its  origin  in  some  irritation 
about  the  genitals,  causing  the  child  to  scratch  or  rub  itself. 
When  it  discovers  the  rubbing  is  accompanied  by  a  pleasurable 
sensation  it  continues  and  forms  the  habit. 

The  habit  is  often  acquired  in  older  children  from  others  who 
practise  it,  or,  not  infrequently,  from  a  vicious  nurse. 

All  queer  tricks,  even  in  an  infant,  which  are  repeated  and 
accompanied  by  flushing  of  the  face,  should  be  viewed  with 
suspicion. 

If  the  hands  are  used  to  produce  the  irritation  they  should 
be  restrained,  especially  in  bed.  If  the  irritation  is  produced  by 
276 


HABITS  2^^ 

rubbing  the  thighs  together,  an  apparatus  made  of  a  piece  of 
padded  wood,  a  few  inches  long,  strapped  between  the  thighs, 
thereby  keeping  them  apart,  will  usually  cure  the  condition. 

The  habit  of  fussing  with  the  foreskin  in  boys  is  unnecessary, 
and  too  often  calls  their  attention  to  the  genital  organs.  Simple 
cleanliness  is  all  that  is  necessary,  and  if  to  accomplish  this  it  is 
necessary  to  do  a  circumcision  it  should  be  done  at  once. 

When  going  to  sleep  and  after  waking  in  the  morning,  chil- 
dren should  be  carefully  watched.  There  should  always  be  some 
plaything  at  hand  to  take  their  attention,  for  children  when 
awake  must  be  busy.  Children  when  playing  together  should 
always  be  under  supervision,  without  their  knowing  that  they 
are  being  watched.  In  every  neighborhood  there  is  always  some 
child  who  will  think  it  his  or  her  duty  to  inform  the  others  of 
the  "  clever  things  he  has  learned."  Eternal  vigilance  is  the 
secret  of  keeping  children  in  the  straight  and  narrow  path.  As 
soon  as  children  are  old  enough  to  understand,  they  should  be 
told  not  to  handle  themselves,  and  given  the  reason  why.  Chil- 
dren should  feel  that  they  can  talk  over  all  matters  freely  with 
their  parents  or  the  nurse.  That  much  harm  in  the  way  of 
reduced  vitality  and  self-restraint  may  result  from  masturbation 
there  can  be  no  doubt.  If  feeble-minded  children  acquire  the 
habit  it  is  apt  to  persist  through  life.  They  are  not  feeble-minded 
because  they  masturbate,  but  they  masturbate  because  they  are 
feeble-minded. 

The  habit  is  a  vicious  one,  and  every  precaution  should  be 
taken  to  prevent  its  formation,  as,  like  every  other  vice,  it 
weakens  the  character  and  normal  functions  of  the  individual. 

Sex  Hvgikxe. — The  question  of  how  much  to  tell  children 
about  sex  hygiene  is  still  an  open  one.  Nurses  doing  child- 
welfare  work  may  find  opportunity  to  give  much  valuable  advice, 
always  under  medical  direction. 

In  private  practice  a  nurse  is  not  expected  to  give  unsolicited 
advice  about  such  subjects.  If,  however,  she  feels  that  informa- 
tion should  be  given,  she  should  first  consult  with  the  parents 
and  the  physician. 


2  78  CARE  OF  INFANTS  AND  CHILDREN 


CALORIC  VALUES  OF  SIMPLE  ARTICLES  OF  FOOD 

Calories 

I  quart  whole  milk 670 

I  quart  skimmed  milk  350 

I  quart  buttermilk  350 

I  pint  skimmed  cream   860 

1  ounce  bread — i  slice  3x4  inches,  3/2  inch  thick  100 

1  slice  toast,  same  size 100 

2  slices  zwieback,  i  ounce   100 

3  soda  or  graham  crackers,    i    ounce    100 

Cooked   cereals,   oatmeal,   cream   of   wheat,   rice,   mashed   potato, 

macaroni,  2  talilespoons   60 

Cane  sugar,  3  tablespoons — i  ounce  120 

Loaf  sugar,  3  large  dominoes  or  6  small  ones — i  ounce 120 

Green    vegetables,    cooked    and    mashed — peas,    beans,    carrots, 

spinach — i  heaping  tablespoon  30 

When  butter   is   added   the   caloric  value   is   correspondingly 

higher. 

Butter,  y2  ounce — a  i-inch  cube   130 

Raw  lean  beefsteak,  i  ounce  28 

Raw  fat  beef,  i  ounce 108 

Raw  veal  steak,  i  ounce  24 

Roast  pork,  i  ounce  69 

Boiled  ham,  i  ounce 146 

Fried  bacon,   i   ounce    249 

Baked  chicken,  i  ounce  60 

Shell-fish,   I  ounce   34 

One  egg,  i  V2  ounces   ^d 

Cream    (thick),   i   ounce    '   87 

Cheese  ( Swiss ) ,  i  ounce  135 

Dried  peas,  i  ounce  108 

Rice  (dried ) ,  i  ounce  117 

Vegetable  puree,  i  ounce 53 

Meat  soup  (broth),  i  ounce  7 

For  diets,  the  nurse  is  referred  to  a  standard  work  on  Dietetics, 
Friedenwald  and  Ruhrah,  or  a  good  cook-book,  such  as  Mrs.  Lincoln's 
or  Mrs.  Farmer'^s. 


INDEX 


Abscesses,  of  breast,  91 ;  in  scarlet 
fever,  250,  of  middle  ear  in  scarlet 
fever,  250 

Abdominal  bands,  35.  (See  cloth- 
ing for  infants.) 

Abdominal  breathing,  19 

Acetone,  in  urine  and  breath,  127 

Adenitis  in  scarlet  fever,  250 

Adhesive  straps,  for  umbilical 
hernia,  35,  36.     (Figs.   13,   14.) 

Adenoids,  cause  of  mouth  breath- 
ing, 55 ;  description  of  adenoid 
face,  198  (Figs.  95,  96)  ;  as  cause 
of  bronchitis,  205;  as  cause  of 
asthma,  205 

Air,  eflfects  of,  18 

Airing,  out-of-doors,  52 

Albumin  milk,  132 ;  in  diarrhoea  and 
intoxication,   188 

Alkaline  laxatives  in  rheumatism, 
232 

Alcohol  for  children,  137 

Anatomy  and  physiology,  8 

Analysis  of  stools,  120 

Anaemia,  24 ;  splenic,  24 

Antitoxin  in  diphtheria,  262,  263 ; 
technic  of  administration  of,  263 

Antrum  of  Highmore,  10;  mastoid, 
10 

Appetite,  135,  139 

Appendicitis,  189 

Appendix  vermiformis,  23 

ArgjTol,  in  eye  infections,  38,  166 

Arm  splints  for  treatment  of 
eczema,  239 

Arsenic  in  treatment  of  chorea,  232 

Arthritis,  multiple  in  scarlet  fever, 
248,  250 

Artificial  feeding,  102 

Artificial  respiration,  31,  (Figs.  10, 
II) 

Asthma,  205;  adenoids  as  cause  of, 
205 

Aspiration  in  pleurisy,  215 


Atrophy,  simple,  due  to  overfeed- 
ing, 122;  simple,  146,  (Figs.  67, 
68) 

Baby,  new-born,  care  of,  30 

Bacteria,  in  digestive  tract,  24 ;  in 
milk,  106 

Bacterial  count  in  certified  milk,  106 

Bands  and  binders,  35 

Barley  flour,  119;  barley  water,  118 

Barlow's  disease  or  scurvy,  135,  152 

Barns,  good  and  bad,  103,  104,  105, 
(Figs.  50,  51,  53) 

Basket  for  new-born  baby,  i;i,  (Fig. 
12) 

Baths,  39 ;  hot  baths  for  convulsions, 
224;  in  typhoid,  268 

Bathing,  39,  temperature  of  bath, 
39;  kinds  of  soap,  39;  water,  40; 
sponge  baths,  40;  shower  baths, 
40,  4:  ;  powders,  40 ;  cold  baths, 
43 ;  for  older  children,  43 

Bath-tub,  folding,  41 

Bed  (see  basket,  33,  Fig.  12),  49; 
Hornsby,  50  (Fig.  20)  ;  screened, 
52   (Figs.  21,  22) 

Bed  sores  in  typhoid,  268 

Belly-band,  35,  74 

Bile,  22  (see  jaundice,  158)  ;  in 
urine,   158 

Binders,  abdominal,  35,  74 

Birthmarks    (Naevi),   241 

Birth-weight,  60 

Bladder,  control  of,  160;  diseases 
of,  163.     (See  urinary  tract,  163.) 

Bleeders,  157 

Bleeding,  from  cord,  33:  of  new- 
born (hemorrhagic  disease),  155; 
gelatine  in  treatment  of,  150; 
from  nose  in  whooping  cough, 
260 

Blood,  circulation  of,  13 ;  fetal 
heart,  14,  15  (Figs.  8,  9)  ;  diseases 
of,  25 ;  microscopic  examination 
of,  25;  transfusion  of,  156;  pres- 
sure of  in  diphtheria,  262 
279 


28o 


INDEX 


Blue  baby,  i6 
Blindness,  38 
Body   movements,   development  of, 

64 
Body-heat,  loss  of,  31 
Body  tluids,  loss  of,  188 
I^oilcd  milk,   in 
Bone,  deformities  and  fractures  of, 

8;  development  of,  8  (see  Rickets, 

149) 
Borax   water,   for   itching  of   skin, 

240 
Bottle  feeding,   102 
Bottle  rack,  107  (Figs.  54,  55) 
Bottles,     103,     109;     thermos,     109; 

nursing  bottles  and  nipples,  116; 

good    and    bad,    117    (Fig.    62)  ; 

care  of,  117 
Bowel,  lesions  of  in  typhoid,  267 ; 

care  of  in  typhoid,  268 
Brain  and  nervous  system,  27,  216; 

lesions  of  brain   due  to  syphilis. 

Breasts,  shape  and  development  of, 
3,  go;  refusal  of,  90;  abscesses  of, 
91  ;  enlargement  of  in  infants,  182 

Breast  feeding,  85 :  causes  of  and 
failures  in,  2 ;  quantity  at  a  meal, 
20;  colostrum,  85  (Fig.  43)  ;  per- 
centage of  cases  when  possible, 
87 ;  Weaning,  87,  95 ;  death-rate  in 
breast-fed  infants,  87.;  immunity 
to  disease  as  result  of,  87 ;  technic 
of.  88 ;  diet  for  mother,  91 ;  posi- 
tion for  nursing,  92  (Fig.  45)  ; 
exercise  for  mother,  93 ;  regular 
hours  for,  93.  94 ;  stools  in,  94 ; 
effects  of  menstruation  on.  95 ; 
effects  of  pregnancy  on,  9.S  ;  mixed 
feeding,  95;  constipation,  96; 
water  in,  96;  of  premature  in- 
fants, 97 ;  tuberculosis,  as  contra- 
indication for,  87,  271  :  in  syphilis, 
274 

Breast  milk,  85  ;  average  daily  secre- 
tion of,  86 ;  determining  quantity 
of,  89:  effect  of  temperament  on 
secretion  of,  89;  secretion  of,  90; 
composition  of,  in 

Bi  ist  pumps,  Engli.sh,  89  (Fig. 
44) ;  Teterelle,  98  (Fig.  48) 


Breath,  acetone  in,  127 

Breathing,  1 1 ;  nose  breathing,  12, 
18,  55;  centres  of,  18;  phenomena 
of,  18;  diaphragm  in,  18;  mouth, 
results  of,  19,  55;  abdominal,  19; 
thoracic,  19;  frequency  of,  19; 
rhythm  of,  19;  Cheyne-Stokes 
character,  ig;  in  new-ljorn,  30 

Brcck-feeder,  97;  in  feeding  child 
with  hair-lip,  181 

Bronchitis  and  asthma,  204 ;  ade- 
noids as  cause  of,  205 

Bronchopneumonia,  207,  210;  chart 
of,  208 

Broths  (see  dietary,  137)  ;  caloric 
value  of,  278 

Bulgprian  bacillus,   131 

Buttermilk,  indications  for,  prepara- 
tion of,  130;  percentage  composi- 
tion of,  130;  caloric  value  of,  130; 
in  diarrhoea  and  intoxication,  188 ; 
as  diet  in  typhoid,  267 

Calorie,  definition  of,  in 

Caloric  values,  of  food  elements, 
128;  of  cow's  and  mother's  milk, 
112,  116;  of  milk  mixtures,  128; 
estimation  of,  128;  of  buttermilk, 
129;  of  malt  soup,  132;  of  simple 
articles  of  food,  278 

Caput  succedaneum,  9 

Ca -bohydrates,  caloric  values  of, 
128,  278;  in  milk  mixtures,  118 

Carbolized  vaseline,  240 

Carbon  dioxide,  13 

Cartilage,  8 

Casein  milk,  132 

Catarrhal  inflammation  of  respira- 
tory tract,  54 

Cathartics,   122 

Cephal  hrematoma,  10  (Fig.  29) 

Certified  milk,   106 

Chancre,  initial  sore  of  syphilis,  272 

Chillblains,  240 

Child-welfare  work,  history  of,  i 

Chest,  deformities  of  from  rickets, 
n;  from  mouth  breathing,  19; 
in  delicate  children,  143 :  phthisi- 
cal, 143 ;  development  of,  144 

Chicken-pox    (varicella),  254 


INDEX 


281 


Chorea  (St.  Vitus'  Dance),  232;  re- | 
lation  to  rheumatism,  232 ;  affec- 
tions    of     heart     in,     22,2 ;     habit 
spasm,  234 

Circulation  of  blood,  12;  fetal  heart, 
13,  14  (Figs.  8,  9) 

Circumcision,  45 

Cleft  palate  (see  Hare  Lip),  179, 
180 

Clothing,  list  of  for  infants,  74,  75; 
excessive  amount  of,  76;  waists, 
good  ai.l  bad,  76  (Figs.  33,  34)  : 
tight  clothing,  76;  underclothing, 
"^T,  for  out-of-doors,  "/T,  for  cold 
weather,  ~7  (Fig.  35);  suspen- 
sion of  from  shoulders,  "JJ  (Fig. 
33,  34):  blanket  wrap,  77 ;  in- 
doors. 78:  in  cases  of  rheumatism, 
231  ;  binders,  35 

Club-foot  (Talipes),  177,  178  (Figs. 
86,87) 

Coccyx,    12 

Cod-liver  oil,  for  delicate  children, 
145;  for  rickets,  151;  for  spasma- 
philia,  225;  in  tuberculosis,  271 

Coffee  for  children,  137 

Colon  bacillus,  in  urinary  tract,  164 

Colon  or  large  bowel,  22, ;  irrigation 
of,  121,  148  (Fig.  69) 

Collapse,  character  of  skin  during,  5 

Colostrum,  85;  composition  of,  85 
(Fig.  43) 

Colic,  in  breast-fed  infants,  88;  in 
artificially  fed  infants,  123;  causes 
of,  90;  gas,  123 

Compresses  for  pneumonia,  213,  214 
(Fig.  100) 

Convulsions  due  to  worms,  196 ;  in 
spasmaphilia,  224 

Congenital  syphilis,  271 

Convalescence,    care    during,   6 

Constipation,  in  breast-fed  infants, 
96:  in  bottle-fed  infants,  120,  121  ; 
in  nursing  mother,  96;  prune  juice 
for,  96;  fruit  juice  for,  122; 
Dextro  Maltose  and  oatmeal 
gruel  for,  I2f ;  fatty  soaps  as 
cause  of,  121 ;  use  of  laxatives 
and  enemas  in,  122 

Contagious  diseases,  245 ;  methods 
of  dissemination,  246 


Condensed  milk,   135 
Coryza,  197;  in  measles,  251 
Cord,    umbilical,    13;    tying   of,   30; 
bleeding  from,  ii  i  care  of,  a;  in- 
fections of,  34 
Cornea,  ulcers  of,   169 
Cough,  due  to  adenoids,  199 
Cough  mixtures,  203 
Cows,  care  of,   102 ;  cleanliness  of, 
102;  diseases  of,  102,  270;  garget, 
105;  foot  and  mouth  disease,  106; 
udders  of,  102;  testing  of  for  tu- 
berculosis,   105;    breeds    of,    113, 
114    (Figs.   59,   60)  ;   tuberculosis 
in,  270 
Cow's  milk  and.  mother's  milk,  per- 
centage of  composition  of,   iii 
Cretinisn   and    myxoedema,   25,    174 

(Figs.  83,  84,  85) 
Cream  in  percentage  feeding,  114 
Cream  dipper,  121   (Fig.  63) 
Crisis  in  lobarpneumonia,  211 
Croup,    spasmodic,    202;    differenti- 
ated    from     membraneous,     202 ; 
steam  tent,  202 
Cry,  character  and  significance  of, 

5.6 

Curvature  of  spine,  due  to  rickets, 

tuberculosis  or  posture,  13,  81,  82 

(Figs.  40,  41) 

Curds  in  stools,  90,  94,  in,  120,  123 

Curds  and  whey,  albumin  milk,  133 ; 

peptonized  milk,  133 
Curdling  milk,  133 
Cyanosis    in    congenital    heart    dis- 
eases,  16 

Dactylitis,  due  to  syphilis,  2']2,  (Fig. 

122) 
Dairies,     sanitary    and    unsanitary, 

103  (Figs.  50,  51.  53) 
Deafness,  due  to  adenoids,  200 
Death-rates   in  large  cities,   i 
Defecation,  23 
Deformities,   of   bone,   8;    of   chest 

wall,  19;  from  rickets,  149-154 
Delicate  children,  143 
Dentition,  68;  symptoms  due  to,  69 

see  Teeth  and  Teething,  68) 
Desquamation,  in  scarlet  fever,  250; 

in  measles,  253 


282 


INDEX 


Desserts,  135 

Development  and  growth,  60 :  of 
muscles,  64 ;  of  muscle  functions, 

64 

Dextro  Maltose,  121 

Diapers,  soiled  as  cause  of  restless 
sleep,  56;  cause  of  urinary  infec- 
tions, 56;  pinning  of,  75  ( I'ig. 
32);  washing  of,  77;  in  gonor- 
rha^al   infections,    165 

Diaphragm  in  breathing,  18 

Diarrhtea,  during  hot  weather,  2, 
188;  from  overfeeding,  6,  90,  188; 
due  to  excess  of  sugar  or  starch, 
120;  fat  or  sugar,  188 

Diet,  of  nursing  mother,  91  ;  during 
first  year,  85,  102 ;  during  second 
year,  135,  138;  after  second  year, 
138,  140;  for  school  children,  140 

Digestion,  errors  of,  as  causing 
pain,  5 ;  in  large  bowel,  23 

Digestion  ferments ;  trypsin,  dias- 
tase, lipase,  rennet,  pepsin,  23 

Digestive  tract,  20;  affections  of,  183 

Diphtheria,  260;  due  to  milk,  106; 
pseudo  or  false,  260;  tonsilitis, 
185 ;  as  cause  of  heart  affections, 
235,  262;  bacillus  of,  260;  use  of 
antitoxin  in,  262,  263 

Discipline,  of  sick  children,  4.  5 ;  in 
feeding  children,  139 

Ducts,  lymphatic,  18 

Ductus  arteriosis  and  ductus  veno- 
sus,  13 

Ductless  glands,  24 

Duodenum,  22 

Drugs,   eruptions   due  to,  241 

Dysentery,  due  to  infected  milk,  106, 
188 

Ears,  development  of  hearing,  29; 
eustachian  tubes,  29 ;  deafness  due 
to  adenoids,  200;  earache,  200; 
abscess  of  middle  ear,  201 ;  drum 
puncture,  201  ;  infections  of,  in 
scarlet  fever,  248,  250 

Eczema  or  exudative  diathesis,  237 
(Fig.  113)  ;  face  mask  and  arm 
splints  in  treatment  of,  239  (Fig. 
115)  ;  vaccination  in  cases  of,  243 
(Fig.  116) 


Eggs    for  young  children,    136 ;   in- 
tolerance of,  137,  240 
Electric  fan,  48 
Empyema,  213 
Endocarditis,    232;    in    rheumatism, 

231  ;  in  scarlet  fever,  248,  250 
Encephalocele,  22;^ 
Enemas,  122,  148  (Fig.  69) 
Epidemics,   due   to   milk,    106 
Epilepsy,  225  ;  due  to  worms,  196 
Epiphyses,    development    of,   8;    in- 
jury to,  8 
Erythema,  241 

Erysipelas,  274;  of  umbilicus,  34 
Eruptions  of  skin,  list  of,  .241  ;  due 
to  drugs,  vaccination,  serum,  anti- 
toxin,    241  ;      chicken-pox,     255 ; 
smallpox,  256;  syphilis,  272   (Fig. 
121) 
Eustachian  tubes,  29 
Eyes,  expression  of,  5  ;  inequality  of 
pupils,  5;  reflexes  of,  28;  develop- 
ment  of   vision,   28;    reaction   of 
pupils  to  light,  28;  care  of,  after 
birth,    38;    defective   vision,    170; 
inflammation  of  lids,  170;  refrac- 
tion,   170;    nearsightedness,    far- 
sightedness and  astigmatism,  170; 
eye   strain,    171  ;   examination   of, 
171  ;  diphtheritic  infection  of.  260; 
gonorriioeal  infection  of.  166 
Exercise,  for  infants,  80  (Fig.  38)  ; 
nursery  pen,   81  ;    for   older   chil- 
dren, 82,  84   (Fig.  42)  :  for  nurs- 
ing mother,  93;   for  delicate  chil- 
dren, 145 
Exudative   diathesis    (eczema),  237 
Excreta  in  contagious  diseases,  247 
Expression  of  face  in  different  con- 
ditions, 5 

Face  mask  for  eczema,  239  (Fig. 
115) 

Face,  expression  of  under  normal 
and  abnormal  conditions,  5 

Fat,  digestion  of,  21  ;  relation  to 
gastric  digestion,  22 ;  in  cow's  and 
mother's  milk,  in;  digestibility 
of.  III;  low  percentage  in  milk, 
128;  producing  diarrhoea,  188;  in 
stools,  94,  1 19 


INDEX 


283 


Feeding,  breast  feeding,  85 ;  arti- 
ficial feeding,  102 ;  intervals  be- 
tween feeding,  9^,  118;  overfeed- 
ing, 90,  122,  123 ;  underfeeding, 
90 ;  mixed  feeding,  95,  1 19 ;  for- 
mula;. 118;  position  for  feeding, 
124  (Figs.  64,  65)  ;  lime  for  feed- 
ing, 124;  during  cases  of  cyclic 
vomiting,  127;  right  and  wrong 
way  to  feed  an  infant,  126;  dur- 
ing second  year,  135-138;  after 
secofid  year,  138-140;  diet  for 
school  children,  140 

Fever,  character  of  skin  during,  5 

Fireplace,  in  nursery,  46 ;  in  sick 
room,  248 

Flexner's  serum,  227,  228 

Flour,  barley,  wheat  and  oatmeal, 
118  brown  flour,  119,  130;  caloric 
value,  128 

Fontanels  (Fig.  9)  ;  time  of  closure 
of,  10;  widening,  10;  early  closure 
of,  28 

Foods,  patent  varieties  of,  134 

Foot  and  mouth  disease  in  milch 
cows,   106 

Foramen  ovale,  13 

Foramina,  13 

Forceps,  injuries  from,  9 

Fractures  of  bone.  8;  greenstick,  8 

Fresh  air,  out  of  doors,  52,  54 

Frost  bites,  79 

Fruit  juices  for  constipation,  122; 
in  treatment  of  scurvy,  154 

Furunculosis,  in  atrophic  infants. 
146 

Gall-stones,  158 
Garments,  74,  78 
Garget,   105 
Gas  on  stomach,  123 
Gavage  in  pylorospasm,  126 
Genitals,  bathing  of,  41  ;  care  of,  41 
German  measles   (Rubella),  254 
Glands,  lymphatic,   17,   18;  enlarge- 
ment of,  18,  206 ;  due  to  vaccina- 
tion, 244;  salivary.  20;  secretions 
of,  20;  ductless,  24;  thymus,  25; 
thyroid,     25 :     parathyroids,     26 ; 
suprarenal,  26:  pituitary  liody,  26: 
pineal,  27;  ovaries  and  testes, '27; 


Glandj,  infections  of  glands  in  scar- 
let fever,  250  ;  medistinal,  enlarge- 
ment of,   in  tuberculosis,  270 

(ji)-cart,  bad,  82  ( I'^ig.  41) 

Goitre,  exophthalmic  (hypertliyroid- 
ism),   176 

Gonorrlnx'al    ophthalmia,    38,    166 

Gonorrha-al  infection  of  urinary 
tract,  165;  isolation,  165 

Growth  and  development,  60 

Gruels,  oatmeal  and  barley,  etc.,  1 18 

Habits,   234,   276 ;    thumb   or   finger 

sucking,    276 ;    masturbation,    27(1 
Habit  spasm,  234 
Haemophilia,  157 
Hsematoma   or  blood   tumor  imder 

scalp,  9    (Fig.  2) 
Hair,  first  38;  in  cretinism,  174 
Hare  lip,  179,  180  (Figs.  89,  90) 
Harrison's  groove,  result  of  mouth 

breathing,  8 
Head,  change  of  shape  at  birth,  9 : 

circumference    at    different    ages, 

27 
Headache,  due  to  defective  vision, 

170 
Hearing,  development  of,  29 
Heat  and  cold,  extremes  of,  54 
Heart,   the,   and   circulation   of   the 
blood,  13;   fetal,  13,  14,  15   (Figs. 
8,  f)  ;  congenital  diseases  of,  16; 
position    of,    16;    apex   beat,    16; 
frequency    of,    at    diflterent   ages. 
16,    17;    variations   under   normal 
conditions,  16;  functional  disturb- 
ances of,  17;  involvement  of,  due 
to  rheumatism,  231  ;  affections  of, 
in    chorea,    234,    235 :    functional 
murmurs,  235  ;  acute  dilatation  of, 
in  whooping  cough,  259;  involve- 
ment of,  in  diphtheria,  261,  263 
Height,  at  different  ages,  62 
Hemorrhages,  of  new-born,  155 
Hernia,    umbilical,    35     (Fig.     13)  ; 
treatment  of,  adhesive  straps,  35, 
36    (Figs.    13,    14)  ;    inguinal    or 
groin,  yarn  trusses  for,  ;^7   (Fig. 
15)  ;  reduction  of,  38:  strangula- 
tion of,  38 


284 


INDEX 


Herpes  zoster,  241 

Hip,  congenital  dislocation  of,  179, 
(Fig.  88)  ;  tuberculosis  of,  271 

Hives  or  urticaria,  due  to  eggs, 
shell-fish,  etc.,   137,  240 

Holstein   cows,    114    (Fig.  60) 

Hot  baths  for  convulsions,  224 

Hot  weather,  as  cause  of  digestive 
disturbances,  122;  cause  of  diar- 
rhoea and  intoxication,   189 

Hydrocele,  38 

Hydrocephalus,   10,  218    (Fig.    104) 

Ice  bag  in  laryngitis,  203 

Ice  box,  unsanitary,  no  (Fig.  57)  ; 
simple  home-made,  in   (Fig.  58) 

Icterus  neonatorum,  158 

Idiots,  microcephalic,  218;  Mon- 
golian, 221    (Fig.  105) 

Immunity  to  disease  in  breast-fed 
infants,  87 

Impetigo  contagiosa,  238  (Fig.  114) 

Inanition,  146 

Incontinence  of  urine,  163 

Incubator,  99  (Fig.  49)  ;  tempera- 
ture of,  99;  removal  from,  100 

Infantile  paralysis,  228;  deformities 
in,  229  (Figs,  no,  in,  112)  ;  or- 
ganism of,  229 

Infectious  diseases,  list  of,  245 ; 
means  of  spreading,  246 

Influenza   (La  Grippe),  206 

Injections,  121,  122   (Figs.  69,  148) 

Intestines,  malformations  of,  187 ; 
lesions  of,  in  typhoid,  267 

Intestinal  parasites,  192 

Intoxication  and  diarrhoea,  188 

Intubation,  for  laryngeal  diphtheria, 
264,  265   (Fig.  118) 

Intussusception,    190 

Iodide  of  potassium,  in  treatment  of 
syphilis,  273 

Irrigation,  rectal,  148 

Jaundice    (icterus),   158;   catarrhal, 

Jaws,  comparison  of,  in  infants  and 

adults,  10  (Figs.  3,  4) 
Jejunum,  22 
Jersey  cows,  1 13 


Joints,  knee,  8;  shoulder,  8;  tuber- 
culosis of,  271 

Keller's  malt  soup,  132 

Kephyr,   131 

Kidney,     affections     of,     in     scarlet 

fever,  249.     (See  urine.) 
Klebs-Lofifler  bacillus,   260 
Knee-joints,  8 
Knockknees,  151    (Fig.  72) 
Koplick's  spots  in  measles,  252 
Koumiss,  131 
Kyphosis,    13,   154    (Fig.   71) 

Lacteals,  17,  23 

Lactic  acid  bacilli  in  milk,  130 

Lactose  in  milk,  1 1 1 

La  Grippe  (intiuenza),  206 

Laryngeal  diphtheria,  261 

Laryngeal  spasm,  202 

Laryngitis  and  spasmodic  croup,  202 

Laxatives,  122 

Leukaemia,  24 

Ligaments,  8 

Lime  salts  in  bone,  8 

Lips,  appearance  of,  5 

Little's  disease  (spastic  paralysis), 
216,  217  (Fig.  102) 

Liver,  size  of,  secretions  of,  22 

Lobarpneumonia,  210;  crisis  in,  211 ; 
temperature  curve  in,  212;  jackets 
for,  213;  compresses  for,  213 

Lockjaw,  34   (see  Tetanus,    172) 

Lordosis,   13.   154    (Fig.  76) 

Lumbar  puncture,  227   (Fig.  108) 

Lungs,    (see   respiratory  tract),   18, 

54 

Lymphatic  glands,  enlargement  of, 
18,  206;  in  vaccination.  244 

Lymphatic  system,  17;  ducts,  nodes 
or  glands,  17,  18;  lacteals,  17 

Malaria,  24 

Malignant  sore  throat  due  to  in- 
fected milk,  106 

Malnutrition,  146 

Malposition,  cause  of  curvature  of 
spine,  13 

Malt-sugar  and  maltose,  121 ;  meas- 
ure and  weight  of,  119;  malted 
milk,  134 


INDEX 


285 


Malt  soup,  Keller's,  132 ;  preparation 
and  caloric  value  of,  132;  in  cliar- 
rluca,  and  intoxication,  188 

Marasmus,  due  to  overfeeding,  122, 
146  (Figs.  67.  68) 

Marriage  of  syphilitics,  274 

Mastoid  antrum,  10;  mastoiditis, 
201 

Masturbation,  276 

Matzoon,  131 

Measles  (see  German  measles),  251, 
253 ;  rash,  252 ;  Koplick's  spots, 
252 

Meals  (see  diets),  137 

Measurements,  61  ;  table  of,  62,  6^ ; 
significance  of,  65 

Meconium,  94 

Mediastinal  glands,  enlargement  of, 
in  tuberculosis,  270 

Melena  neonatorium  (the  haemor- 
rhagic  disease),  155 

Membrane,  appearance  of,  in  diph- 
theria, 261 

Membraneous  croup,  261 

Meningitis,  meningococcus,  226 ; 
Flexner's  serum  in  treatment  of, 
227 ;  lumbar  puncture.  227  ( Fig. 
108)  ;  causes  of,  226 ;  breathing  in, 
19:  forms  of,  226;  cerebrospinal, 
226;  tuberculous,  270 

Meningocele,  222 

Menstruation,  beginning  of,  141 
(see  puberty) 

Mercury,   in  treatment  of   syphilis, 

273 
Microcephalus,  28,  218  (Fig.  103) 
Middle  ear,  abscess  of,  200,  201,  248, 

250 
Milk,  character  of,  in  different  ani- 
mals, 2 ;  use  of  cow's  milk  in  in- 
fant feeding,  3 :  coagulation  of, 
21  ;  composition  of  breast  milk  and 
cow's  milk,  86,  in;  average  daily 
•  secretion  of,  86 ;  supply  of  cow's 
milk,  102 ;  sanitary  conditions  for 
production  of,  102,  103  (Figs.  50; 
51,  53)  ;  milk  pail,  102  (Fig.  52)  ; 
bottles,  103,  108;  caps  for  bottles, 
103 ;  from  herd  or  one  cow,  103 ; 
diseases  affecting  cows,  103 ;  tu- 
bercle  bacilli    in,    103,    105,    270; 


Milk,  streptococcus  in,  106;  as  car- 
rier of  disease,  106,  246,  260;  cer- 
tified, 106;  pasteurization  of,  106, 
107,  109;  percentajge  composition 
of,  hi;  modification  of,  for  m- 
fants,  112;  utensils  for  modifying 
milk,  116;  boiling  of,  11 1;  for- 
mulae, 1 18 ;  special  preparation  of, 
129,  135;  substitutes  for,  128.  129; 
fat  free,  129,  131 ;  buttermilk,  129; 
predigested  or  peptonized,  133 ; 
condensed,  135 

Milk  crusts,  237 

Milking  machines,  102  (Fig.  53) 

Milk  pail,  102 

Milk  stations,  2 

Milk  formulae,  118 

Miscarriage,  due  to  syphilis,  272 

Mixed  feeding,  95,  119 

Modified  milk,  112,  119;  percentage 
method,  114;  simple  dilutions  of, 
114;  utensils  for,  116 

Mongolism,  mongolian  idiots,  220 
(Fig.  105) 

Mothers'  milk,  percentage  composi- 
tion of,  III 

Mouth,  20;  care  of  in  new-born,  30 

Movements,  muscular,  5 

Mucous  membrane,  character  of,  5 

Mumps   (parotitis),  256 

Muscles,  movement  of,  5 

Muscular  functions,  definition  of,  64 

Myocarditis,  235 

Myxcfidema  and  cretinism,  25,  174 
(Figs.  83,  84,  85) 

Naevi,  241 

Naps,  57 

Nasal  catarrh  (see  coryza),  197 

Neo-salvarsan      in      treatment      of 

syphilis,  273 
Nephritis  in  scarlet  fever,  250 
Nervous  system.  27;   instability  of, 

28:  diseases  of.  216 
Nestle's  food,  134 
Nettle  rash    (urticaria),  240 
New-born  infant,  care  of,  30 
Nipples,  fissure  in.  91 ;  shields  for. 
91    (Fig.  46)  ;  care  and  develop- 
ment of,  before  birth  of  child,  3 ; 
openings  in,  90 


286 


INDEX 


Nipples  and  bottles,  ii6;  good  and 

bad,  11/  ;  care  of,  117 
Nipple-shield,  91    (Fig.  46) 
Noma  (gangrenous  stomatitis),  i<S4 
Nose,  care  of  new-born,  30;  nasal 

diphtheria,   261 
Nurse,   the,   child   welfare   work  as 

sphere   for,  3;   protecting  herself 

against  infection,  248 
Nursery,    temperature    of,    31,    47; 

ventilation  of,  46;  heating  of,  48; 

moisture  in,  lighting,  fireplace,  46 ; 

equipment  of,  46,  51  ;  nursery  pan, 

81    (Fig.  39) 
Nursing,  technic  of,  88;  reasons  for 

refusing  the  breast,  90,  91  ;  regu- 
lar hours  for,  93,  94 
Nutrition    (see  Delicate   Children), 

143 ;  diseases  of,  146 

Oatmeal  flour,  118 

O'Dwyer's  tubes  in  laryngeal  diph- 
theria, 264  (Fig.  117) 

Oesophagus,  malformations  and  af- 
fections of,  186,  187 

Omentum,  tuberculous  involvement 
of,  271 

Opisthotonos,  228  (Fig.  109) 

Opthalmia,  neonatorum  (gonor- 
rho^al  opthalmia),  38,  166;  technic 
and  care  of,  168  (Fig.  182) 

Orange  juice,  122;  in  treatment  of 
scurvy, _ 155 

Orchitis  in  mumps,  257 

Ovaries,  27,  256,  257 ;  involvement 
of,  in  mumps,  257 

Overfeeding,  5,  6,  22,  90;  with  fat 
and  sugar,  123;  cause  of  digestive 
disturbances,  122;  cause  of  diar- 
rhoea and   intoxication,   188 

Oxygen  in  blood,  13 

Oxide  of  zinc  ointment,  40 

Pacifiers,  96 

Pain,  causes  of,  5 ;  sensibility  to,  29 
Pancreas,  secretions  of,  22 
Paralysis,     obstetrical,     216     (Fig. 

loi)  ;     facial,    216     (Fig.     loi)  ; 

spastic     (Little's     disease),     216, 

217  (Fig.  102)  ;  infantile,  228,  230; 

following  diphtheria,  262 


Parasites,   intestinal,   192 
Parathyroid  glands,  26 
Pasteurization    of    milk,     106,     109 

(Figs.  54,  55,  56) 
Patent  foods,  134 

Pediculosis  capitus  (head  lice),  241 
Peeling  in  scarlet  fever,  250 
Pemphigus,  241 
Pepsin  in  stomach,  21 
Peptonized  or  predigested  milk,  133 
Percentage  composition  of  mother's 

milk,  and  cow's  milk,  in 
Pericarditis,  235,  236,  250 
Peritonitis,  tuberculous,  271 
Pertussis  (whooping  cough),  258 
Peyer's    glands,    ulceration    of,    in 

typhoid,  267 
Pharyngitis  and  tonsilitis,  varieties 

of,  i8s 
Pharynx,    retropharyngeal    abscess, 

186 
Photophobia     (see    measles),     251, 

253 
Physiology  and  anatomy,  8 
Pigeon  breast  in  rickets,   153    (Fig. 

.74) 

Pin  or  thread  worms,  196;  in  stools, 
196  (Fig.  94) 

Pineal  gland,  2y 

Pitting  in  chicken-pox,  255 ;  small- 
pox, 256 

Pituitary  body,  26 

Placenta,  13 

Pleural   effusion,   213 

Pleurisy,  213,  215;  tubercular,  215; 
aspiration  in,  215 

Pneumonia,  bronchopneumonia,  207 : 
lobar,  .10;  temperature  curve  in 
lobar,  212;  jacket  for,  313;  com- 
plication of  whooping  cough,  259 

Pneumococcus,  21  r 

Poleomyelitis,.  228;  deformities  in. 
229  (Figs,  no.  III,  112);  organ- 
ism of,  229 

Polypod  growth  in  umbilicus,  34 

Position  or  posture,  effects  of,  81  ; 
curvature  of  spine  as  result  of 
bad  position,  81,  82,  84  (Figs. 
40,  41)  ;  in  older  children,  144 

Potassium  iodide  in  treatment  of 
syphilis,  273 


INDEX 


287 


Pott's  disease  (tuberculosis  of  the 
vertebrjE),  269  (Fig.  120) 

Powder,  talcum,  unscented,  40 ; 
stearate  of  zinc,  40 

Pregnancy,  as  reason  for  weaning, 

95 

Premature  infants,  weight  of,  97 ; 
Breck-feeder  for,  97;  feeding  of, 
97;  wet  nurse  for,  98;  caloris  re- 
quirements of,  98;  breast  pumps 
for,  98  (Fig.  48)  ;  incubator  for, 
99  (Fig.  49);  mortahty  of,  99; 
due  to  syphilis,  272 

Prenatal  care  of  mother,  3 

Prolapse  of  rectum,  191 

Proteids,  digestibility  of,  iii;  in 
cow's  and  mother's  milk,  in 

Prune  juice  for  constipation,  96,  122 

Psoriasis,  241 

Puberty,  141  ;  gain  in  weight  during, 
63;  nervous  system  during,   141 

Pulmotor   for  artificial   respiration, 

31 

Pulmonary  valve  and  artery,  con- 
structions of,  16 

Pulse,  frequency  and  variation  of, 
16,  17;  manner  of  taking,  17;  in 
diphtheria,  262 

Pupils,  reaction  to  light,  28 

Purpura,  155 

Pyelitis,  pyelo-cystitis,  164 

Pyloro  spasm,  124-126 

Pyloric-stenosis,  124-126 

Pylorus,  22 ;  pyloric  valve,  22 

Quarantine,  definition  of,  245  ;  par- 
tial, 245 
Quantity  of  milk  in  breasts,  86 

Rash,  due  to  vaccination,  244 ;  due 

to  antitoxin,  262,  263 
Reaction    of    stools    in    breast   and 

bottle-fed  babies,  119 
Rectal  irrigation,  148 
Rectum,  prolapse  of,  192  (Fig.  91 ) 
Regurgitation  of  food,  124 
Rennet  in  coagulation  of  milk,  21 
Respiration,   artificial   in   new-born, 

31  (Figs.  10,  11)  ;  during  sleep,  55 
Respiratory  system,   18;  breathing, 

18;  catarrhal  inflammation  of,  54 


Rheumatism,  inflammatory,  231  ; 
due  to  streptococcus,  231  ;  due  to 
tonsilitis,  231  ;  heart  involvement 
in,  231,  235;  salicylates  in,  232; 
clothing  in,  232;  relation  to 
chorea,  232 

Rickets,  149;  as  cause  of  chest  de- 
formities, II,  143,  151 ;  as  cause  of 
spinal  deformities,  13 ;  due  to 
overfeeding,  122;  cod-liver  oil 
for,  151  ;  tenderness  of  bones  in, 
150;  temperature  in,  150;  sitting 
position  in  (Fig.  70)  ;  bowlegs, 
151  (Fig.  71)  ;  changes  in  bones, 
enlarged  epiphyses  in,  150;  richitic 
rosary  (Fig.  78)  ;  crania  tabes, 
151;  open  fontanels  in,  151  ;  the 
teeth,  delayed  eruption  of,  151 ; 
pigeon  breast,  151  (Fig.  74)  ; 
shape  of  head  (Fig.  ys)  !  scoliosis, 
lordosis,  kyphosis,  154  (Figs.  75, 
76,  77)  ;  knock-knees,  151  (Fig. 
72) 

Rochelle  salts,  232 

Round  worms,  194 

Rul)ber  gloves,  in  care  of  contagi- 
ous cases,  247 

Rubella    (German  measles),  254 

Sacrum,  12 

Safety  pins,  as  cause  of  crying,  6 
Salts  in  mother's  and  cow's  milk,  1 1 1 
Salicylates,  in  treatment  of  rheuma- 
tism,  232 
Salivary  glands,  22 
Salvarsan    and    neo-salvarsan,  for 

treatment  of  syphilis,  223 
Sandals,  79 
Scabes  (itch),  241 
Scales,  51,  67  (Figs.  24,  25) 
Scaling,    in    scarlet    fever,    250;    in 

measles,  253 
Scalp,  injuries  of.  during  birth,  9 
Scarlet  fever,  248;  due  to  infected 
milk,  106 ;  heart  involvement  in, 
235 ;  streptococcus  as  cause  of, 
249;  middle  ear  affection  in,  249; 
kidney  aff'ections  in,  248,  249; 
strawberry  tongue  in,  250;  de- 
squamation in,  250 


288 


INDEX 


Scoliosis,  13,  154   (Fig.  75) 

Scorbutus   (see  scurvy),  135 

Screened  house,  144 

Screened  bed,  52 

Scurvy  or  Barlow's  disease,  135, 
152;  hemorrhages  in,  155  (Fig.  78) 

Sedatives  for  convulsions,  224 

Senses,  special,  28 

Septic  sore  throat,    from  milk,   106 

Sex-hygiene,    discussion    of,    277 

Shock,  38 

Shoes,  correct  shape  of,  78,  79  (Figs. 
36,  37) 

Sigmoid   flexure,   23 

Silver  nitrate  in  eye  infections,  39, 
167 

Sinuses,  involvement  of,  206  ;  maxil- 
lary or  antrum  of  Highmore,  10; 
frontal  sphenoidal,  ethmoidal,   10 

Sitting,  time  for,  64 

Standing,  time  for,  64 

Skull,  8 

Skeleton,  8 

Skin,  normal  and  abnormal  char- 
acter of,  5 ;  feeling  of  during 
fever,  5 ;  character  of,  38 ;  vermix 
caseosa,  39;  irritation  of,  40,  41; 
abscesses  in,  148;  affections  of, 
237,  241 ;  eruptions  of,  241 ;  list 
of,  241 

Sleep,  in  and  out-of-doors,  52,  53 ; 
amount  in  twenty-four  hours,  55; 
effects  of,  55 ;  respiration  during, 
55  ;  temperature  of  roqm,  55  ;  with 
mother,  55 ;  rocking  and  walking 
during,  56;  causes  of  restlessness 
during,  56 ;  position  during,  56 ; 
after  third  year,  57;  naps,  57 

Smallpox  (variola),  255;  vaccina- 
tion in,  255 

Smell,  development  of  sense  of,  29 

Snuffles,  due  to  syphilis,  272 

Soap-stick,  121 

Soap,  40;  irritation  from,  40 

Soda,  applications  for  itching  in 
urticaria,   240 

Sore  mouth    (stomatitis),   183 

Soup  (see  dietary),  137;  caloric 
value  of,  278 

Spasmophilia,  202,  224;  feeding  in, 
225 


Special  senses,  28 

Speech,  64,  65 

Spinal  canal,  12,  13 

Spinal  cord,  12,  13 ;  cauda  equina,  13 

Spina  bifida,  222  (Figs.  106,  107) 

Spinal  column,  12  (Fig.  7)  ;  natural 
curves  of,  12;  deformities  of,  due 
to  rickets  and  tuberculosis,  13; 
kyphosis,  lordosis,  scoliosis,  13, 
154;  curvature  as  result  of  erect 
position.  40,  41 ;  Pott's  disease  of, 
269  (Fig.  120) 

Spirochaeta  pallida,  organism  of 
syphilis,  271 

Spleen,  24;  enlargement  of,  24;  in 
typhoid,  267 

Spoiled  infants,  124 

Sponging  with  cold  water,  205 

Sprue  or  thrush,  183 

Sputum  in  pulmonary  tuberculosis, 
270 

Stables,  sanitary  and  unsanitary, 
103,  104,  105 

Starches,  digestion  of,  20 

Stearate  of  zinc,  40 

Steam  tent,  202  (Fig.  97)  ;  in  diph- 
theria, 261,  266  (Fig.  119) 

Sterilization  of  milk,  106,  109 

Stomach,  position  of,  capacity  of,  at 
different  ages,  20;  functions  of, 
20;  pepsin  in,  21;  hydrochloric 
acid  in,  21  ;  lactic  acid  in,  21 ; 
rennet  in,  21  ;  muscular  contrac- 
tion of,  21 ;  pyloric  and  cardiac 
portion,  21 ;  time  required  in 
emptying,  22 

Stomatitis,  183 ;  ulcerative  and  gan- 
grenous, 184 

Stools,  observation  of,  6,  94,  120; 
in  breast-fed  infants,  94;  in  arti- 
ficially fed  infants,  119,  121 ;  ef- 
fects of  cathartics  on,  94 ;  regu- 
larity of,  94,  121;  meconium,  94; 
number,  120;  green,  94,  120;  fat 
in.  120,  121:  curdy,  120;  black. 
120;  blood  in,  120;  loose  and  acid. 
120;  microscopic  examination  of, 
121,  193 ;  worms  and  eggs  in,  193 

Stoves,  in  sick  room,  248 

Strabismus,  5,  29;  following  diph- 
theria, 262 


INDEX 


28y 


Streptococcus,  in  milk,  io6 ;  cause 
of  rheumatic  arthritis,  231  ;  in 
scarlet   fever,  248,  249 

St.  Vitus'  dance  (chorea),  232;  re- 
lation to  rheumatism,  232;  habit 
spasm,  234 

Submaxillary  glands,  involvement 
of,  in  mumps,  256 

Sucking,  20 

Sugar,  by  weight  and  measure  table, 
J 19;  cane,  119;  malt  and  milk, 
119;  as  cause  of  diarrhoea,  188; 
caloric  value  of,  128 

Suprarenal  glands,  26 

Suppositories,    121 

Sutures,  8,  9;  fontanels  (Fig.  9); 
time  of  closure  of,  9;  early  closure 
of,  28:   in   microcephalus,   218 

Sweets,  injury  from,  136 

Syphilis,  271  ;  Hutchinson  teeth,  ^2, 
73 ;  in  wet  nurse,  100 ;  chancre,  in 
272;  eruptions  of,  272  (Fig.  121)  ; 
mortality  in,  272 ;  snuffles  in,  272 ; 
dactylitis,  272 ;  Spirochaeta  pallida, 
271 ;  salvarsan  and  neo-salvarsan, 
223 ;  marriage  of  syphilitics,  274 

Table,  folding,  43,  49 ;  dressing,  49 
Talcum  powder,  40;  stearate  of  zinc, 

41 

Talipes    (see  Clubfoot) 

Talking,  64,  65 

Tape  worm,  193 

Taste,  29 

Tea  for  children,   137 

Teeth,  at  birth,  10.  68;  first  teeth 
(Fig.  27)  ;  time  of  appearance  of, 
68,  69;  effects  of  illness  on,  69; 
permanent,  70,  ^2  (Fig.  28);  ir- 
regularities of,  2  (Figs.  29,  30)  ; 
Hutchinson's  teeth,  -j^,  73,  273 
(Fig.  31)  ;  care  of,  "/jt'^  effects  of 
decayed  teeth,  T}, ;  delayed  and 
irregular  eruptions  of,  due  to 
rickets,  15T ;  in  syphilis,  273 

Teething,  68 :  symptoms  due  to,  69 

Temperature,  sensibility  to,  29;  of 
body,  58;  of  room,  31;  for  bath, 
39 :  mode  of  taking,  58,  59 

Tents  and  screened  houses,  144 


Testes,  27;  involvement  of,  in 
mumps,  256,  257 

Tetanus  and  erysipelas,  through  the 
umbilicus,   34;   chapter  on,   172 

Thermos  bottles,  109 

Thorax,  the,  character  and  shape  of, 
10;  infants  and  adults,  11  (Figs. 
5,  6)  ;  in  breathing,  11 

Thoracic  breathing,   19 

Tliroat,  appearance  of,  in  diphtheria, 
261 

Thrush  or  sprue,   183 

Thumb  sucking,  276 

Thymus,   25 

Thyroid  extract,  in  treatment  of 
cretinism,  176 

Thyroid  glands,  25 

Tongue,  abnormal  appearance  of,  5 

Tongue-tie,  181 

Tonsils,  removal  of,   186 

Tonsilitis,  cause  of  rheumatism, 
231  ;  heart  involvement  in,  231  ; 
from  infected  milk,  106;  pharyn- 
gitis,   184 

Touch,  sensibility  to,  29 

Toxin  of  diphtheria,  260 

Tracheotomy,  laryngeal  diphtheria, 
264,  265   (Fig.  117) 

Transfusion  of  blood,   156 

Trusses,  yarn  for  hernia,  })y  (Fig. 
is)  ;  protection  of,  from  dis- 
charges, 38 

Trypsin,  23 

Tuberculosis,  268;  as  cause  of  spinal 
deformities,  13 ;  in  cows,  105 : 
testing  cows  for,  105 ;  tubercular 
pleurisy,  215;  varieties  of  tubercle 
bacilli,  269;  bacillus  in  milk,  270; 
sputum  in,  270;  cod-liver  oil  for, 
271 ;  as  contra-indication  for 
nursing,  87;  possibility  of  inheri- 
tance, 270;  Pott's  disease  in,  269 
(Fig.  120);  meningitis  in,  270; 
of  joints,  271 

Tuberculous  peritonitis,  271 

Typhoid  fever,  24,  266 ;  due  to  in- 
fected milk,  106:  bacillus  of,  266, 
268 ;  Peyer's  glands,  ulceration  of, 
266 


290 


INDEX 


Ulcers,  due  to  syphilis,  273 

Umbilical  cord,  13;  tying  of,  30; 
bleeding  frorii,  33  ;  care  of,  33,  34  ; 
infections  of,  34 

Umbilical  hernia,  35  (Fig-  13)  ; 
treatment  of  adhesive  straps,  35, 
36   (Figs.  13,  14) 

Umbilicus,  infections  of,  34;  poly- 
poid growth  in,  34 

Underfeeding,  5,  6,  90 

Urine,  159;  examination  of 
mother's,  3;  ammoniacal,  121; 
acetone  in,  127;  bile  in,  158;  quan- 
tity of,  159;  control  of.  159:  in- 
continence of,  163 ;  reaction  of, 
and  clinical  examination  of,  160; 
securing  specimens  of,  apparatus 
for  (Figs.  79,  80),  161,  162;  nor- 
mal constituents  of,  162 ;  bacteria 
in,  162;  in  scarlet  fever,  251 

Urinary  tract,  diseases  of,  163 

Urination,  frequency  of,  159 

U  rot  r  opine,  165 

Urticaria  (hives)  due  to  eggs  and 
other  articles  of  diet,  137,   140 

Vaccine,  242 

Vaccination,  242 ;  technic  of,  243 ; 
general,  as  result  of  eczema  (Fig. 
116)  ;  for  smallpox,  255,  256; 
variola  (smallpox),  255;  after 
exposure  to  smallpox,  256; 
against   typhoid,  268 

Varicella,  254 

Vaseline,  carbolized  for  itching  of 
skin,    240 

Vegetables    (see  diets) 

Ventilation,    46 

Vermiform   appendix,   23,    189 

Vernixcaseosa,  39 

Vertebrse,  number  and  character  of, 
12  (Fig.  7) 

Vision,  development  of,  28;  defec- 
tive, 170 


Vomiting,  due  to  improper  feeding, 
C;  overfeeding,  90;  due  to  milk 
used  too  soon  after  parturition, 
106;  recurrent,  cyclic  or  inter- 
mittent, 124,  126;  feeding  in  cases 
of  vomiting,  127;  regurgitation 
due  to  posture,  124 :  due  to  pyloro- 
spasm,  124;  acetone  in  urine  and 
breath  during,  127;  in  whooping 
cough,  259 ;  in  scarlet  fever,  246 ; 
in   meningitis,   226 

Vulva,  diphtheritic  infection  of,  260 

Waists,  76  (Figs.  33,  34) 

Walking,   time    for,  64 

Wash  cloths,  40 

Wassermann  reaction,   lor,  274 

Water  for  babies,  88 ;  excessive 
amounts  of,  96;  in  summer  diar- 
rhoea,  188 

Weaning,  87,  95 

Weighing,  technic  of,  66 

Weight,  average  at  birth,  60;  of 
twins,  60;  loss  of  during  first 
weeks,  (So ;  gain  during  first  year, 
61  ;  during  puberty,  63 ;  signifi- 
cance of,  65,  66 ;  scales,.  67  (Figs. 
24.  25)  ;  weight  chart,  68  (Fig. 
26)  ;  loss  due  to  overfeeding,  122; 
paradoxical  gain  in,   122 

Wet  nurse,  for  premature  infants, 
90;  chapter  on,  100;  syphilis  in, 
100;  technic,  loi ;  diet,  loi ;  exer- 
cise for,   loi 

Whey,  preparation  and'  percentage 
composition    of,    131 

Wheat  flour,  118 

Whooping  cough  (pertussis),  258, 
259 

Worms,  in  intestinal  tract,  193 ; 
tape  worm,  round  worm,  pin  or 
thread  worm,  194,  195  (Figs.  92, 
93)  ;  eggs  of,   195,   196 

X-ray,  use  of,  in  tuberculosis,  270 

Zinc  oxide,  stearate,  40 


SSS»;Sffi,^.r«-«.^ 


^    001379  034 


STATE  NOKMAL  SCHOOL 
LIBRARY 


